Vascular System

VASCULAR DISORDERS AND
IT’S MANEGMENT
By: Jyoti Makwana

Guided by: Dr.Parita Dave
Vascular rehabilitation,subin solomen ,5th edition kishner
Introduction
•Blood and lymph flows through

circulatory system respectively
•The circulatory system consists
of the heart and blood vessels
through which the blood
circulates
•The lymphetic system consists
of lymph nodes, lymph oragans,
and lymph vessels, through
which colorless lymph flows .
•It consists of central and
peripheral lymphoid system
 Central lymphoid includes,
 Thymus
 Bone marrow
 Peripheral lymphoid system
 lymph nodes
 Spleen
 lymph vessels

 Vascular disorders causing insufficient circulation to
the extremities, can result in significant physical
impairments and subsequent loss of function of either
upper extremities or lower extremities .
 Disturbances of structure or function of the circulatory
systems are broadly classified as acute or chronic
peripheral vascular disease (PVD) and can be caused by
a number of underlying pathologies of the arterial,
venous, or lymphatic systems, including occlusion,
inflammation, vasomotor dysfunction, or neoplasms.

Biomechanics of circulation
 Compliance of the blood vessels

 In the human body the veins are an important blood
reservoir.
 Normally they are partially collapsed and oval shape
 A large amount of blood can be added to the venous
system before the veins become distended to the
point where further increments in volume produce a
large rise in venous pressure

 The veins are therefore called capacitance vessels.
 At rest ,at least 50% of the circulating blood volume
is in the systemic veins

Windkessels vessels and effect
 Windkessel vessels are the aorta and its major

branches
 The main pulmonary arterial trunk is also a
windkessel vessel
 These blood vessels contain elastic fibers
 If they are stretched, it elongates ,but recoils and
regains the original length as soon as the streched is
withdrwan
 So aorta suddenly distends

 Aorta stores energy during ventricular systole,
which is released by heart during the diastole
 Now the aorta recoils and surge forward with
reserved blood
 Applications are as follows:
 During ventricular diastole although ventricular
pressure falls very low, aorta is able to maintain
diastole BP of 80mmHg

 During systole it prevents too much rise of pressure
 In old age arteries stiffen, the windkessel effect
deteriorates, the systolic BP becomes high, but the
diastole becomes low

Starling’ s law
 The rate of filtration at any point along
a capillary depends on a balance of
forces sometimes called starling forces
 One of these factor is the hydrostatic
pressure gradient (the hydrostatic
pressure in the capillary minus the
hydrostatic pressure of the interstitial
fluid
 The other force is the osmotic pressure
gradient across the capillary
wall(colloid osmotic pressure of
plasma minus colloid osmotic presure
of interstitial fluid)

FAHRAEUS-LINQVIST EFFECT
 capillaries were diameter is small the velocity can be

less this results in high viscosity
 This can cease blood flow in the capillaries
 Fahraeus-linqvist effect blood flow is still possible

even though the diameter is small
 Causes of this effect is axial streaming

 In a narrow vessels ,the RBCs of the blood occupy
the central or axial line and the plasma occupies the
periphery
 This phenomenon is called axial streaming
 Small branches divide from these large branches

therefore consists of plasma and few RBCs the
hematocrit values is reduced

 The vascular disorders are categorized into three
type
 Disorders of the Arterial system
 Disorders of the Venous system
 Disorders of the Lymphatic system

Arterial system
•Areteries carry rich blood away from
the heart ,branching off into section
with smaller diameters called
arterioles ,leading ultimately to
capillaries.
•Artery have three layered walls that

give them strength and elasticity .
•The walls of the artery are generally

thicker than the veins because they
have to bear strong blood flow
pressures generated by the heart.

Venous system
•Veins returns oxygen depletded blood from
tissues and organs to the heart.
•Veins also have three layered walls but they
do not need to be as muscular or elastic as
arteries because the blood pressure in veins is
lower than in arteries.
•Venous walls are so thin that they do not hold
theair shape well under stress ,collapsing or
tearing when stretched.
•When the walls of veins weaken, or are
enlarged ,the valves cannot function properly
and blood pools in the veins.
•Eventually they become distended ,leading to
varicose veins.
•If a valve or valves do not close properly, this
leads to a condition known as a venous reflux.

LYMPHATIC SYSTEM
 The two primary function of the lymphetic system

are to protect the body from infection and diseases
via the immune response and to facilitate
movement of fluid back and forth between the
bloodstream and the interstitium ,removing excess
fluid ,blood waste, and protein molecules in the
process of fluid change.
 Lymph fluid is first absorbed at the capillary level,
then channeled through small vessels called
procollector,and finally picked up by the
larger ,valved vessels called collectors.
 The collectors have a contractile properties ,smooth
muscles ,and valves
 Lymphatics are even thinner and more likely to
collapse under pressure than veins
 Excess lymph fluid is transported through the
thoracic duct and emptied into the venous angles at
the left and right jugular vein trunks

 Under normal condition ,lymph flow is not adversely
affected by gravity
 Under abnormal conditions, the lymphatic system
may exhibit excess lymph pooling related to
gravity ,especially in the lower extremities

 Lymphetic
Lymphetic ca
capillaries procollector,and
Collectors

TYPES OF VASCULAR
DISORDERS
Disorders of the arterial Disorders of the Disorders of the
system venous system lymphetic system
Acute arterial occlusion •Thrombophlebitis

• arteriosclerosis •Lymphedema
•Deep vein thrombosis
• atherosclerosis •Chronic venous
• arteriosclerosis obliterans insufficiency
• Thromboangitis •Varicose veins
obliterans(burger’s disease)
• Raynaud’s disease
Vascular rehabilitation,subin solomen ,5th edition

kishner
atherosclerosis
Acute
arteriosclerosis
Arterial
disorde Aneurysm
rs
Chronic
Buerger’s disease
Raynaud’s disease
Acute Superficial venous

Peripher Thrombosis
al
Venous DVT
vascular disorders
disease Varicose vein
Chronic
Chronic venous
insufficiency
Pulmonary
embolism
Lympheti Lymphedema
c
disorders

PERIPHERAL VASCULAR DISEASE
Peripheral vascular
diseases(PVD)refers to
any diseases or disorders
of the circulatory system
outside of the brain and
heart
Peripheral vascular
disease is the most
common disease of
arteries
EPIDEMIOLOGY
• the PVD is a major cause of morbidity and mortality in

the population
• The PVD of the lower extremities affects 20million
people in india
• Recent estimate by the WHO show that india already
has the largest number of diabetic patients
• Approximetly 10 to30%of patients with PAD presents
with classic claudication and 20-40% have atypical leg
pain
• Nearly 50% of all patients with PAD are asymptomatic

RISK FACTORS OF PAD
 Age
 Male gender
 Arterial hypertension
 Diabetes
 Low high –density lipoproteins
 Chronic kidney diseases

SCALES TO RATE SEVERITY OF IC
Rutherford categories
Fountain stages
0. Asymptomatic
Asymptomatic 1. Mild claudication
II a. Mild claudication 2. Moderate claudication

3. Severe claudication
II b. moderate to severe
4. Ischemic rest pain
claudication 5. Minor tissue loss

6. Major tissue loss
III. Ischemic rest pain
IV. Ulceration or gangrene

ARTERIOSCLEROSIS
•it is a general term used to include

all condition with thickening and
hardening of the arterial walls

Types
 arteriosclerosis
hypertensive Monk berg atherosclerosis
hyaline hyperplasic necrotizing

HYALINE ARTERIOSCLEROSIS
 CAUSES:
 Physiologically due to aging
 Pathologically due to hypertension or diabetes

PATHOGENESIS
 Permeability of the vessel wall is increased in

hypertension , diabetes, immunological reaction or
due to aging
 This results in the leakage of components of plasma
across the vascular endothelium

HYPERPLASTIC ARTERIOSCLEROSIS
 CAUSES
 Malignant hypertension
 Hemolytic uremic syndrome
 Scleroderma
 Toxemia of pregnancy

PATHOGENESIS
 Systemic hypertension , which results in endothelial

injury ,hypoxia or immunologic damage leads to
increased permeability
 This is followed by proliferation of smooth muscle
cell with fibrosis

NECROTIZING ARTERIOLITIS
 Necrotizing arteriolitis is a form of hyaline

arteriosclerosis with necrotic changes
 CAUSES:
 Age related degenerative process

MONCKEBERG ARTERIOSCLEROSIS
 Monkeberg arteriosclerosis is the calcification of

media of large and medium sized muscular arteries
especially of the extremities and of the genital tract
 causes
 Age related degenerative process

PATHOGENESIS
• Deposition of calcium salts in the media produces

pipe stem like rigid tubes without causing narrowing
of the lumen

ATHEROSCLEROSIS
•Atherosclerosis is a specific
form of arteriosclerosis
affecting primarily the
intima of large and medium
sized muscular arteries, and
is characterized by fibro
fatty plaques or atheroma

INCIDENCE
 The highest incidence occurs in the 6th and 7th

decades of life
 There is an increased prevalence of peripheral
atherosclerotic disease in individuals with diabetes
mellitus, hypercholesterolemia , hypertension or
hyperhomocysteinemia and in cigarette smokers

RISK FACTORS
Major constitutional Major acquired risk factor Minor risk factor
factor
 Major constitutional factor
Age Hyperlipidemia Enviromental influences
 Age
 Gender
Gender Hypertension Obesity
 Genetic factor
Familial factorSmoking
Genetic
 factor Oral contraceptives
 Racial factor
Familial factor Diabetes mellitus Lack of physical activity
Racial factor Blood clot

PROCESS OF
PATHOPHYSIOLOGY
Trapped down & oxidization Endothelial cell
Atherosclerosis-develop clinical set aberration+ abnormal
ofTrapped
LDL in down
endothelium-which
& oxidization of up of PAD oxidative stress=
contain specific phospholipids
LDL in endothelium-which increased endothelial
superoxide anion
contain specific phospholipids
Endothelium produced NO or Increased oxidant degradation

the accelerated degradation of Abnormalization of
endothelium derived relaxing
of endothelium derived NO or vasomotor tone of
factors such as NO prostaglandin endoperoxide, atherosclerotic vessel
PGH2

CLINICAL FEATURES
 SYMPTOMS
• The illiac femoral ,popliteal arteries are commonly
affected
• The pain usually occurs, while walking or climbing stairs
and stops when rest
• It is usually a dull, cramping pain,heaviness,tightness,or
tiredness in the muscles of the leg
• Pins and needles ,tingling or complete anesthesia may be
present in hands or feet and increased by exercise
• Buttock pain
• Numbness or aching pain in the feet or toes ,while resting
• Ulcer or wound on a leg or a foot that will not heal

 SIGNS
• Intermittent claudication
• Ischemia
• Decreased or absent pulse
• Presence of bruits
• Hair loss,thickened nails,smooth or shiny skin
• Pallor of the sole of the feet
• Hyperemia
• Peripheral edema

INVESTIGATIONS
DIAGNOSTIC TEST
Invasive techniques Non invasive techniques
ABI
ultrasonography CT angiography MRI angiography

Treatment
 Treatment for atherosclerosis focuses on reducing

symptoms and preventing further progression of
the disease
 GOALS:
 Relieving symptoms
 Reducing risk factors in an effort to slow or stop the
building of plaques
 Lowering the risk of formation of blood clots
 Widening or bypassing plaques clogged arteries
 Preventing atherosclerosis related disease

Medical treatment
 Cholesterole medications: statins

 Antiplatelet medication: aspirin
 Beta blocker medication:metoptolol,propranolol
 ACE inhibitor:analapril,quinapril
 Vasoactive drugs:pentoxyfylline
 Calcium channel blocker:verapamil,diltiazem
 Water pills(diuretics)
 Vitamin E
 Omega -3 polyunsaturated fatty acid

Surgical menagement
 Angioplasty
 Cryoplasty
 Endarectomy
 Bypass surgery

ANEYURYSM
Permanent abnormal dilatation

of blood vessel occurring due to
congenital or acquired
weakening or destruction of
vessel wall
Aneurysm can occur in both
veins and arteries , but they are
much more common in
arteries ,specially the aorta and
it’s major branches
The abdominal and thoracic
aortas are the most frequent
locations for arterial aneurysm
Etiology
 aneurysm
congenital acquired
traumatic degenerative infection

Pathophysiology
Occurrence and Lower Repeated trauma of a reflected
expansion of extremities arterial wave on the distal aorta
aneurysm in a have higher
given segment of arterial
arterial tree resistance for
involves local circulating the
hemodynamic blood
factors
It injures a weakened
Aneurysmal degeneration aortic wall

Clinical features
Carotid aneurysm Aortic aneurysm
Blurred or double vision Chest pain
Loss of consciousness for brief time Shortness of breath
Dilated pupils Cough
Stiff neck Hoarseness
Numbness, weakness and paralysis on Dysphasia

one side of face
Tachypnea Congestive heart failure
Tachycardia Congestion of head,neck,and upper

extremities

Investigation
 Blood
 Urine analysis
 ECG
 Aortography
 Ultrasound scanning
 Angiogram
 CT
 MRI

Medical management
 medical therapy should be initiated as soon as

diagnosis is considered
Patient should be admitted to an intensive care unit

monitoring hemodynamic and urine output
For acute dissection adrenergic blockers should be

administered parenteral using intravenous
propanolol,metoprolol,or short acting small to
achieve minimum heart rate of 60 beats per minute
 The edition of a parenteral ACE – inhibitor , such as
enalaprilat
 Isolated use of direct vasodilaters

Surgical management
 Arterial ligation
 Aneurysmorrhaphy

Raynaud’s disease
 Vasospasm of the acral or distal

often triggered by cold stress and
relieved by warmth or
pharmacological agents
It is characterized by episodic
digital ischemia, manifested
clinically by the sequential
development of digital
blanching ,cyanosis, and rubor of
the fingers or toes following cold
exposure and subsequent
rewarming
Types
 Primary Raynaud's
 Secondary Raynaud's

Risk factors
 Age
 Smoking
 Living in a cold climate
 Injuries to the hand and feet
 Exposure to certain workplace chemicals such as
vinyl chloride
 Repetitive actions with the hands , such as typing or
using vibrating tools

Etiology
 Disease and conditions that directly damage the

arteries or damage the nerves that control the
arteries in the hands and feet
 Repetitive actions that damage the nerves that
controls the arteries in the hands and feet
 Injuries to the hands and feet
 Exposure to certain chemicals

Pathophysiology
cold
 me optional
Emotional stress
Decreased blood vasospasm Blanching, pallor

supply
Veins dilate cyanosis
Relieved rewarming rubor

vasospasm
Dolor
pain

Investigation
 Liver function test
 Cold stimulation test :
 a cold stimulation test can be used to trigger Raynaud's
symptoms. for this test ,a small device that measures
temperature is taped to the fingers .the hands are then
exposed to cold(they are usually briefly put into ice
water)the hands are then removed from the cold, and
the device measures how quickly the fingers returns to
their normal temperature .if one has Raynaud's it may
make more than 20 minutes for the fingers to return
their normal temperature

Medical management
 CCB,nitroglycerine- to reduce vascular tone

 Alpha adrenergic antagonists-to increase
vasodilatation
 Plasmaphoresis-to reduce blood viscosity

Prophylaxis
 Wearing mittens or heated gloves

 Protection from cold and moisuture
 Avoid vibrating tools(power saws, jack hammer)
 Often changing duties at work is required
 Make regular repeated fist
 Medications which could be triggers ,such as beta
blockers, ergot –containing substances and oral
contraceptives should be avoided

Surgical management
 Sympathectomy:

Buerger’s disease
•Buerger’s disease is an
inflammatory occlusive vascular
disorder involving small and
medium sized arteries and veins in
the distal upper and lower
extremities
•It is characterized by the absence
or minimal presence of
atheroma ,segmental vascular
inflamation ,vaso –occlusive
phenomenon and involvement of
small and medium sized arteries and
veins of the upper and lower
extremities

Etiology
 While the cause of Thromboangitis obliterans is not

known, there is a definite relationship to cigarette
smoking in patient with this disorders

Pathophysiology
Initial stage of TAO Thrombus may
polymorphonuclear As the disease progress
 Initial
leukocytes stage
infiltrate the
develop in the mononuclear cell, fibroblast
vascular lumen and giant cell replace the
wall of arteries and vein neutrophills
Perivascular
fibrosis and
recanalization

Clinical features
 Intermittent claudication
 Raynaud’s phenomenon
 Migratory superficial vein Thrombophlebitis
 Weakness in hands and feet
 Swelling
 Sores
 Discoloration
 Parasthesia
 Impaired distal pulses

Investigations
 Laboratory investigation – ESR raised in autoimmune

disorders
 Angiography /arteriography
(digital ,palmer,plantar,tibial,peroneal,radial and
ulnar arteries)
 Echocardiography
 Excisional biopsy:pathological examination of an
involved vessel disorders
 X-ray : exclude cervical rib,or carpal tunnel syndrome
 Doppler ultrasound :gives quantitative information
about the stenosis
Medical management
 Absolute discontinuation of tobacco

 Vasodilators :to increase circulation
 Analgesics: to relieve pain
 Thrombolytic therapy :streptokinase
 Skin hygiene
 Antibiotics for the wound infection

Surgical management
 Upper thoracic or lumbar sympathectomy:

 to relax the arterial muscle and increase the vessel
lumen thereby improving the blood supply to the
extremities

Spinal cord stimulator implantation
 SCS relieves pain by pain gait theory and increases

vasodilatation .
 It is useful for therapeutic option in BD particularly
for pain control and wound healing and may delay
the need for amputation in selected patients

Complications
 Ulcerations
 Gangrene
 Infection
 Need for amputation

Prevention of complication
 Use of well fitting protective footwear to prevent

foot trauma and thermal or chemical injury
 Early and aggressive treatment of extremities
injuries to protect against infections
 Avoidance of cold enviroments
 Avoidance of drugs that lead to vasoconstriction

Venous disorders
 Superficial vein thrombosis

 thrombosis and inflammation of inner walls of the
greater or lesser saphenous veins or their tributaries

Etiology
 Trauma to the vessel wall a drip needle or pressure

externally due to tight garments or position of a limb
 It is associated with intravenous catheters and
infusion

Pathology
Irritation produced Thrombus

changes in tunica intima formation
Thrombus attached to the

embolus vein

Clinical features
 Pain
 Redness, warmth and tender cord
 Affected area may be red and edematous

Investigations
 Phlebography is used to find out the thrombosis

Treatment
 Treatment is primarily supportive :

 NSAIDs
 Antibiotics
 Anticoagulant therapy

Deep vein thrombosis
Presence of thrombus
within a deep vein and the
accompanying
inflammatory response in
the vessel wall is termed as
deep venous thrombosis
(DVT) OR Thrombophlebitis

Incidence
 DVT occurs less frequently in the upper extremities

than in the lower extremities ,but the incidence is
increasing because of greater utilization of
indwelling catheters

Risk factors
 Recent surgery
 Neoplasms
 Trauma
 Fractures
 Immobilization
 Acute myocardial infarction,congestive heart
failure,stroke
 Pregnancy
 Hypercoagulable states

Pathogenesis

Damage to Thrombus resulting on
intima causes Venous stasis increase occlusion of the vessels
platelets to be accumulation of platelets lumen.
deposited on the
vein wall
The inflammatory response in the

Further the thrombus along the vessels wall may be minimal or
vessels to the next junction with characterized by granulocyte
vein. infiltration, loss of endothelium and
edema.
Pulmonary embolism

Clinical features
 Most common complaint is cramp-like pain in the

calf.
 Unilateral leg swelling(edema around the joint distal
to the area.
 Local warmth
 Erythema
 Tenderness may be present along the course of the
involved veins.
 Distention of superficial veins.
 Appearance of prominent venous collaterals
Investigations
 D-dimmer:A degradation product of cross-linked

fibrin is often elevated in patients with venous
thrombosis.
 Duplex venous ultrasonography
 Doppler ultrasound: measure the velocity of blood
flow in veins.
 Magnetic resonance imaging
 Venography: contrast medium is injected into a
superficial vein of the foot and directed to the deep
system by the application of tourniquets. The
presence of a filling defect or absence of filling of the
deep veins is required to make the diagnosis.
Treatment
 Bed rest
 Anticoagulants therapy:
Heparin, warfarin
 Thrombolytics :
streptokinase,urokinase
 vena cava filter(greenfield filter)

Complications
 Pulmonary embolism
 Chronic venous insufficiency

Varicose vein
Varicose veins are

dilated, tortuous
superficial veins that
results from defective
structure and function
of the valves of the
saphenous veins
Incidence
 The most common in 40-50 years

 Females are more affected than males.

Types
primary secondary
Superficial system Deep venous insufficiency
Incompetent perforating veins

Pathology
Vein wall dilates at weak areas and the valves become

incompetent
With contraction of calf muscles there is proximal pressure

on deep vein
This Pressure is not transmitted to the superficial veins

because of valves and communicating veins
When these valves become incompetent the pressure pushes

the blood into a superficial vein which dilates and
lengthens.
Etiology
 Failure of development of valve in the vein

 Damage to the valve due to thrombosis
 From intrinsic weakness of the vein wall
 From high intraluminal pressure
 Rarely from arteriovenous fistulas

Predisposing factors
 Pregnancy
 Occupation necessitating constant standing
 Low-fiber diet
 Constipation
 Tight corsets or gaters
 Contraceptive pills which have estrogen
 Family history
 Secondary to DVT

Clinical features
 Dull ache
 Pain and pressure sensation in the leg after prolong
standing
 Cramp in the calf muscle
 Fatigue in the legs with difficulty in walking
 Feeling of heaviness in the leg
 Ankle edema
 Skin ulcerations near the ankle
 Rarely a varicosity ruptures and bleeds

Investigations
 Doppler ultrasound scan:It can easily identify reflux

or back-flow of blood in the veins.
 Varicogram: A cuff will be placed around the lower
calf and the dye injected into the veins on the back
of the foot.

Conservative treatment

Surgical management
 Endogenous obliteration of the sephenous vein

 Sclerotherapy :
 it is a procedure in which a sclerosing solution is
injected into the involved varicose vein and a
compression bandage is applied .

Complication
 Hemorrhage
 Ulceration
 Phlebitis
 Edema
 Pigmentation

Pulmonary embolism
 The term pulmonary embolism implies clinically

significant obstruction of a part or the whole of the
pulmonary arterial tree, usually by thrombus that
becomes detached from its site of formation
outside the lung and is swept downstream until
arrested at points of intrapulmonary vascular
narrowing.

Types
Thrombotic pulmonary embolism Due to DVT
Others
No thrombotic pulmonary embolism Air embolism
Fat embolism
Tumor emboli
Amniotic fluid embolism

Pathophysiologyical effects
 Increased pulmonary vascular resistence due to

vascular obstruction or platelet secretion
This increases the afterload on the right ventricle
which results right ventricular failure
Decline pulmonary blood flow reduces the filling left
ventricle,
No longer able to maintain systolic blood pressure

• V/Q mismatch and impaired gas exchange :
Pulmonary embolism produces mismatching of
ventilation and perfusion by preventing blood in the
pulmonary artery
Increased alveolar dead space
Impaired gas exchange

Clinical features
 Dyspnea
 Chest pain and chest tightness
 Syncope
 Cough
 Palpitation
 Tachypnea
 Hypotension
 Juglar venous engorgement and neck vein
distention

 Auscultation
 Pulmonary component of the second heart sound
depends on the degree of pulmonary hypertension
 Diminished or absent breath sound
 Pleural friction rub
 Wheeze due to secondary bronchoconstriction

Investigations
 Blood test :WBC (Leukocytosis),bleeding

time,clotting time(to check hypercoagulable states)
 D-dimer
 Arterial blood gases :
 Classical findings:
 Reduced PaO2
 Normal or low Paco2(respiratory alkalosis)
 Mixed acidosis(respiratory or metabolic)

Chest x-ray
 Fleischner sign : Enlarged pulmonary artery

 Hampton hump: Peripheral wedge of airspace
opacity and implies lung infarction
 Westermarck's sign: hyperlucency due to oligemia
 Knuckle sign: abrupt tapering or cutoff of a
pulmonary artery secondary to embolus
 Opacities: horizontal opacities in lower zone
 Signs of pleural effusion: blunting of costophrenic
angle

Westermark’s sign

Hampton’ s hump

Fleischner sign
Enlarged pulmonary artery

Echocardiogram

interpretation :
S1Q3T3 pattern(prominence of the s wave in
lead 1 ,Q wave in lead 3,with T wave inversion
in lead 3)

Medical management
 Supplemental oxygen therapy :all patients who are
hypoxic should be given o2 therapy
 Resuscitation: massive PE may have circulatory
collapse
 Anticoagulants : heparin ,foundaparinux(new
parenteral synthetic coagulants)
 Thrombolitic therapy: streptokinase,urokinase
 Pharmacologic support:pt are intubeted and
mechanical ventilator may be needed
 Respiratory support
 Pulmonary embolectomy
Chronic venous insufficiency
•The term chronic venous insufficiency
describes a condition that affects the
venous system of the lower extremities
with venous hypertension causing various
pathologies including
pain,swelling,edema,skin changes and
ulceration
•CVI is often used to exclude
uncomplicated varicose veins ,vericose
veins have incompetent valves with
increased venous pressure leading to
progressive dilatation and tortuosity

CEAP classification
Classification type description
clinical 0 No venous disease
1 Telangiectasia
2 Varicose vein
3 Edema
4 hyperpigmentation
5 Healed ulcer
6 Active ulcer
etiologic Congenital Present since birth

primary Undetermined etiology
secondary Associated with post
thrombotic,traumatic

Anatomic distribution Superficial Great and short
deep sephenous veins
Illiac,gonadal/
femoral,profunda,poplite
al,tibial,and muscular
veins
perforator
Thigh and leg perforating
veins
Pathophysiologyical Reflux Axial and perforating veins

Obstruction Acute and chronic
Combination of both Valvular dysfunction and
thrombus

Clinical features

Venous claudication
Obstruction of the deep

venous system may lead
to venous claudication or
intense leg cramping with
ambulation

Investigations
 Continues wave Doppler studies

 Venous duplex imaging
 Photoplthyesmography
 Demography
 Ambulatory venous pressure monitoring

Ambulatory venous pressure monitoring Air plethysmography

Treatments
 Conservative therapy
 elevation of the leg
 Compressive garments
 Pharmacological therapy
 Coumarins
 Flavonoids venoactive
 Sapnosides

Wound and skin care
 Keep affected area well moisturized to reduce the

skin breakdown and possibility of infection
 Statis dermatitis treated with the topical steroids
 Hydrocolloids and foam dressings are available to
control fluid drainage and resultant maceration of
the skin

Surgical treatment
 Sclerotherapy
 Venous phlebotomy
 Vein transplant
 Valve reconstruction

Lymphedema
Lymphedema is defined as
excessive accumulation of
lymphetic fluid in the interstitial
spaces due to impaired function of
lymphetic circulation
According to Foldi et al ,
Lymphedema is chronic and
progressive swelling caused by a
low output failure of the lymphetic
system ,resulting in the
development of a high protein
edema in the tissues
Classification
 According to the cause of its development
Primary Lymphedema secondary Lymphedema
infection inflammation Trauma
Cancer and
its
treatment

Risk factors
Disease related factors Cancer status
Treatment –related factor Surgry:involving lymph nodes in the
axilla,groin or pelvis
Radiotherapy :involving lymph nodes in
the axilla ,breast or groin
Postoperative events:seroma
formation ,cording,
thrombosis ,venepuncture,infection

Clinical features
 Location :on hands and feet

 Severity: pitting brawny and weeping edema
 Increased size of the limb
 Sensory disturbances
 Stiffness and limited R.O.M
 Psychological effect

Patient-related factors Concurrent medical conditions and
medicines
Demographic
issues :age,weight,activities involving
the limb
Skin conditions :psoriasis, eczema and
trauma

Pathophysiology
Increased Decreased plasma Increased plasma hydrostatic

permeability of osmotic pressure pressure
the capillary walls
Reduced lymphatic system

transport capacity

Stage 0 Swelling is not evident ,this stage exist months or years before edema
becomes evident
stage1 Accumulation of tissue fluid subside with elevation ,the edema is pitting
Early Limb elevation alone rarely reduces swelling pitting edema is manifest
stage 2
Late There may or may not be pitting as tissue fibrosis is more evident
stage2
stage3 Tissue is hard and pitting is absent ,skin changes occurs such as
thickening, hyperpigmentation ,increased skin folds ,fat deposits

Medical management
Diuretics
Benzopyrones
Diethylcarbamazine : for fillariasis

Surgical management
 Lymphetic bypass procedure: obstructed lymphatic

vessels have been anastomosed to vessels in the
venous system in an attempt to drain the swollen
limb and normal healthy lymph vessels have been
transplanted into areas where Lymphedema exists
in order to connect poorly functioning lymph vessels
with normal ones.

 Liposuction: The procedure involves several
incisions along the length of the limb
through which a cannula is inserted.
 The subcutaneous fat is sucked out through
the cannula under vacuum.
 Liposuction does not correct lymph drainage
and results are only maintained through the
continued use of high compression garments.

Assessment of patient with peripheral
vascular disease
 Subjective examination :
 Patient history : The initial step is to obtain a
complete history requisition of medical records can
be useful in understanding the patient’s previous
medical record can be useful in understanding the
patient’s medical condition
 Age and gender
 Limbs affected
 Pain assessment

 Rest pain
 Effects of heat and cold
 Parasthesia
 History of superficial phlebitis
 Involvement of other arteries
 Impotence
 Past history
 Personal history
 Family history
 Occupational history

Objective examination
 Change in color
 Pallor : arterial occlusion
 Purple-blue appearance :severe ischemia
 Discoloration of the skin :venous disorder
 Signs of ischemia
 Thinning of skin
 Diminished growth of hair
 Trophical changes :brittle nails,transverse ridges and
minor ulceration

Palpation
 Skin temperature :radiometer ,thermostat

 Capillary refilling
 Palpation of blood vessel : palpation should
focus on the more distal arteries along with
femoral,popliteal ,dorsalis pedis and posterior tibial
arteries
 In ischemic limb :disappearance of pulse
 In case of aneurysm:expansile pulsation

Grading of pulse
0 Absent
1+ Diminished
2+ Normal

 Palpation of edema :pitting ,non pitting
0 No clinical edema
1 Slight pitting (2mm)with no visible distortion
2 Somewhat deeper pit(4mm)with no readily
detectable distortion
3 Noticeably deep pit(6mm)with the dependent
extremity full and swollen
4 Very deep pit (8mm)with the dependent extremity
grossly distorted

Examination
 Auscultation : useful in identifying a bruit

 Blood pressure: to exclude affection of
subclavian,brachiocephalic or axillary artery
 Gait assessment :
 Motor examination : R.O.M. and muscle strength
examination
 Sensory examination : light touch
pressure

Semmes-weinstein monofilaments

Girth measurements

 Volumetric measurement :
 It is a quantitative system to measure edema
 The volumeter ,a clear acrylic rectangular box
(13”×5”× 9”) with a spout at the top of one of the
short sides was filled with water untill water rushed
out of the spout
 Once the water level was stable ,the patient placed
one foot in the volumeter and the displaced water
collected and measured in a graduated cylinder

Special test for PVD
PVD
Venous filling time ,rubor of dependency Stemmer’s test
Lymphedema
Arterial disorders Venous disorders
Claudication Test,
ABI,pole test Trendelenburg Perthes test DVT
test
Deep vein incompetnce
Superfiscial veins Perforator veins incompetence Cuff test,homman

incompetence test,moses test
Percussion test,cough test

Torniquet test

Rubor of depenendency
 Patient position :supine lying color of both feet

is examined
 Procedure :the affected limb is then elevated for
several seconds, and lower back to the original
position
 The time is recorded for color of the tested foot to
match the stationary foot
Vascular rehabilitation,subin solomen ,5 th edition kishner

 Interpretation : if arterial disease is present it
may take longer than 20-30 seconds for color to
return and will usually be bright red
 If the color returns immediately ,this may denote
the presence of venous insufficiency

Claudication test
 Procedure : the patient begins to ambulate

using treadmill or an unobstructed level
surface
 Interpretation :the claudication test is recorded as
the time or distance at which this painful symptom
occurs

Cuff test
 Patient position :supine lying

 Procedure: this test is performed by placing a
blood pressure cuff around the lower leg and
inflating cuff.
 Interpretation: the patient is unable to tolerate
cuff pressure grater than 40mmhg ,there is high
probability of an active DVT

HOMAN’S TEST
 Patient position : supine lying
 Procedure : forceful squeeze of the calf region or
passive dorsiflexion of the calf by the examiner

 Interpretation: if test is positive severe pain
expressed by the patient is indicative of DVT

MOSES TEST
 Patient position : prone lying
 Procedure :tap the calf muscle side to side
elicits pain
 Interpreatation : if pain is elicit than test is
postive for DVT

Percussion test
 It is useful for valve competency

 Procedure : lower extremity in a dependent
position ,the greater saphenous vein is
palpated distal to the knee with one hand
while the vein is tapped approximately 6-8
inches

Trendelenburg test
 Purpose :assess if the valves are functioninig
properly, especially within the perforation system

 Patient position :supine lying
 Procedure :patient is positioned supine lying and
the lower extremity is elevated to approximetly 75 ̇

to allow venous blood to empty .

 A torniquet is placed around the thigh to prevent
superfiscial venous back flow the lower extreimity

place than dependent position
 Interpretation : process of venous filling is
observed .should the superficial veins fill quickly the

valves of the perforator vein become incompetent

 If immediate filling is noted with release of torniquet
,the superficial system has incompetent valves .
 These test can be repeated with the tourniquet at
different levels (above knee and below knee) to
further pinpoint the level of valvular incompetence
 This is called as torniquet test

PERTHES TEST
 PURPOSE : to access the vein patency

 Patient position :standing
 Procedure : torniquet is placed is placed on thigh and
they walk for 5 minutes .
 Interpretation : positive perthes test means the
superfiscial veins become further dilated,tortous,and
the patient complaints of severe pain
STEMMER’S TEST
 Purpose : this test can be performed to clarify the
pressure or evidence of lymphedema

 Procedure : pick up the skin fold at the base of the
second toe of the affected extremity
 Interpretation: inability to pick up the skin fold

Investigations
 ABI
 Normal ratio of the ankle to brachial index is greater

than 0.95 for screening on atherosclerosis in the leg
 Pressure in each leg were measured and the ABI
calculated seprately for each leg

normal Normal=one or slightly higher
>1.2 Falsely elevated artriosclerosis ,DM
1.2-0.95 Normal
0.95-0.75 Mild arterial +claudication
0.74-0.5 Moderate arterial +rest pain
<0.50 Severe arterial occlusion

Post exercise ABI
 It is recommended to measure the post exercise ABI

to differentiate arterial claudication from non
arterial claudication
 A 15-20% drop in post exercise ABI compaired to
resting ABI is indicative for the PAD

 Patient were requested to undergo standered
exercise testing in accordance with the physcian
advice
 According to the protocol ,the patient was
requested to perform 30 active pedal planterflexion

 Immediately after exercise the patient was to lie in
supine lying
 Then meausure the blood pressure of the arm and
blood pressure of the tibialis posteriore arteries
were measured
 The total ABI ratio is lower in upperlimb and lower
limb arteries
Toe systolic pressure index
•This index is useful for

diabetus because digital
vessels are usually spared
from sclerosis.
•It is especially in detecting
individual at high risk of
gangerene,ulceration
associated with occlusive
arterial disorders

Assessment of physical perfomance in
arterial disorders
Methods Measures Endpoints Comments
Aerobic •12 lead ECG •Serious •Cycle protocols

Treadmill (1-2 •BP dysrhythmias can underestimate
METS/stage, •4 point •>2 mm ST severity of PAD.
preferred) claudication scale segment •Record time for
depression or pain onset &
elevation maximal pain.
•Ischemic threshold
•T wave inversion
with significant ST
change
•SBP>250mm hg
DBP >115mm hg
Endurance Time to maximal Maximal pain Record time of pain
Constant work rate pain onset & maximal
pain.

Methods Measures Endpoints Comments
Neuromuscular •Speed May change with

Gait analysis •Step rate disease
•Step length progression.
Functional Distance •Time to maximal •Record time of

•6 minute walk test pain pain onset &
•Maximal pain maximal pain.

Physical activity measurments
Pedometer and
.
accelerometers can measures
the daily physical activity

Walking impairment questionnaire
 It is the specific tool to assess self reported walking

ability
 In each domain score ranging from0 to 100 with
lower score indicating lower perfomance

QOL instruments in arterial and
venous disorders
 SF36
 Nottingham health profile : to meausured
percived health problems on daily activities
 The six dimension measured include
energy,pain,sleep,physical mobility ,social
isolation and emotional response

Chronic lower limb venous insufficiency questionnaire
 CIVIQ have 20 items with dimension of

pain ,physical functioning,psychological
functioning and social functioning

Disease specific QOL instruments for varicose vein
 It is 15 items questionnaire with dimension of

symptoms,pain,interference with daily
activity and work ,treatment and concern
about appearance

Physiotherapy management

VASCULAR REHABILITATION
 Vascular rehabilitation is a noninvasive exercise

program that improves maximal walking distance in
patient with claudication, pain in the legs with
activity that subside with rest
 Componenet of vascular rehabilitation include,
 Patient education
 Addressing risk factor modification
 Stress education technique together with the
exercise and walking programs .

Benefits
 Relief of pain
 Promote a greater sense of well being
 Decreased risk of further complications of arterial
insufficiency
 Decreased discomfort with activity
 Increases walking distance and endurance
 Teaches about risk factors for vascular disease
 Reduce potential need for surgery

TEAM MEMBERS
 Vascular surgeon
 Physiotherapist
 Nurse
 Exercise physiologist
 Dietician

Contraindication of exercise program
 ET should not be performed until medical clearance,
based on physical examination, screening & graded
exercise test has been completed.
 ET should not be performed when there are concomitant
co-morbidities which can limit exercise tolerance.

OUTPATIENT VASCULAR
REHABILITATION
 A participants follows the program ,under the
direction of vascular surgeon
There are 12 week outpatient sessions
1)acute vascular rehabilitation
2)maintenance of vascular rehabilitation
vascular rehabilitation may increases walking
tolerance by 400-500%

Vascular rehabilitation program
Weeks Exercise Intensity Ambulation
1-3 Isometrics:quadriceps ,hamstri Daily 3 sets Half mile or just
ng 15 repetition prior to the point
Active R.O.M. –ankle 2-3 times daily of claudication
pumps,heel slide Monitor daily
4-6 Resisted exercise Daily 3 sets Half to 1 mile or to
Standing on toes 20 repetition the point of
SLR 2-3 times daily claudication
Wall squat
Hip,knee,ankle resisted
exercise
7-10 Continues resisted exercise , Daily 3 sets 1 mile distance as
Resistance as much as 20 repetition tolerated
tolerable 3 times daily

Upper limb training vs lower limb
training
 Arm cranking exercise
 Lower limb cycle ergometer
 Rate:50rpm followed by 2 minutes of rest
 Time :2ominutes
 Upper limb training could be used in the early stages
of exercise rehabilitation program until patients feel
more comfortable and confident to engaging for
lower limb exercise

Physiotherapy management for acute
arterial disorders
 Goals
 To decrease ischemia by restoration or
improvement of blood flow
 To protect limb and skin care

Contraindication for physiotherapy
Contraindication to exercise in acute General contraindication in acute
arterial occlusion arterial occlusion
Graded ambulation or bicycling is Prolong positioning during bed rest,
discontinued if the leg pain increases which could cause pressure on and
rather than decreases potential breakdown of skin
Patient with resting pain should not Local direct heat on the involved
participate in active or passive exercise extremity becsuse of the potential for a
burn to the ischemic tissue
Use of support hose,which may
increases peripheral resistance to blood
flow
Presence of skin irritatio or ulceration Restrictive clothing that could copromise
blood flow

For chronic arterial disorders
 Traditional Buerger’s exercises and modified

Buergers exercise
 Principal: This exercise uses the principle of
gravity
 Rationale: These exercise imprrove the
collateral circulation.
 Procedure: It consists of three phases

i. Leg in elevation of 45 for horizontal until skin
blanches for 2 min. the purpose of this phase is to
assist venous circulation. As the leg is elevated
gravity pull back the blood towards the heart,
which empties the veins
ii. In traditional buerger’s exercise patient sits with
leg dependent position until skin color is bright red
for 3 minutes for arterial claudication

 Patient lies with leg horizontal until color returns to
normal for 5 minutes
 Frequency: 5 times for 3 sets in a day
 Prognosis sign : improvement is determined by
decrease in the time required for change in the skin
color changes

 Contrast bath :3 minutes dipped into hot bath and 1
minute dipped into cold bath
 Iontophoresis
 Repetative active range of motion exercise
 Gentle streaching exercise
 Connective tissue massage
 Patient education

RATSCHOW’S EXERCISE
 Purpose : these are the specific exercise to

improve colleteral circulation
 Procedure: the lower extremities are elevated to a
45-90̇ angle and ankle joint rotation is exercised
until redness appears
 A positive effect is achieved by repeating and
carrying out this exercise several times a day

Exercise prescription in PAD
Components Aerobic exercise Resisted exercise Flexibility exercise
Mode Treadmil walking 8-10 exercises of Static stretch of all

Track walking major muscle group major muscle
groups
Traininig intensity Initial Volatigue itonal Streth to tightness

Set by result of the fatigue at the end of the
tradmillStart work 19-20 RPE range of motion but
load brings on Stop 2-3 repetition not to pain
claudication pain before volitional
fatigue
Duration 35 minutes 1 set of 3-20 15-30 sec

repetitions 2-4 time each
stretch
Frequency 3-5 times per week 2-3 days per week Minimal:2-3 days
perweek

Title Wearable sensor technology efficacy in peripheral vascular disease
Author Normahani, Pasha MSc∗,†; Kwasnicki, Richard PhD†; Bicknell, Colin
MD∗,†; Allen, Louise MSc∗; Jenkins, Mike P. MS∗; Gibbs, Richard MD∗;
Cheshire, Nicholas MD†; Darzi, Ara MD†; Riga, Celia MD∗,†
Method thirty-seven patients with IC were recruited and randomized into
intervention or control group. The intervention consisted of a
feedback-enabled, wrist-worn activity monitor (WAM) in addition to
access to SEP. The control group was given access to SEP only. The
outcome measures were maximum walking distance (MWD),
claudication distance (CD), and quality of life as measured by the
VascuQol questionnaire. Participants were assessed upon
recruitment, and at 3, 6, and 12 months.
Results Patients in the WAM group showed significant improvement in MWD

at 3 and 6 months (80–112 m, to 178 m; P < 0.001), which was
sustained at 12 months. The WAM group also increased CD (40 vs 110
m; P < 0.001) and VascuQol score (4.7 vs 5.8; P = 0.004). The control
group saw a temporary increase in VascuQol score at 6 months (4.5
vs 4.7; P = 0.028), but no other improvements in MWD or CD were
observed. Significantly higher improvements in MWD were seen in
the WAM group compared with that in the control group at 6 months
(82 vs −5 m; P = 0.009, r = 0.47) and 12 months (69 vs 7.5 m; P =
0.011, r = 0.52).

Title Effects of a 12-Week mHealth Program on FunctionalCapacity and
Physical Activity in Patients With PeripheralArtery Disease
Author Brian D.DuschaMSaLucy W.PinerMSa et al
Method Twenty patients were randomized into usual care or a 12-week

mHealth intervention consisting of patient education, smartphones,
and physical activity trackers. Patient education was disseminated
through smartphone and a daily exercise prescription was given based
on steps per day. Primary outcomes were 12-week changes in peak
VO2 and claudication onset time; and changes in physical activity
measured by steps per/day and minutes of exercise per/week.
Results mHealth patients significantly increased peak VO 2 from 15.2 ± 4.3 to
18.0 ± 4.8 ml/kg/min (20.3 ± 26.4%; p ≤0.05), while usual care did not
change from 14.3 ± 5.4 to 14.5 ± 5.7 ml/kg/min (1.0 ± 6.9%; NS).
Comparison of these changes resulted in a significant difference
between groups (p ≤0.05) for peak VO2. 12-week mHealth program in
PAD patients with IC can improve peak VO2 and claudication onset
time; and mHealth interventions represent a promising alternative
therapy for those patients who cannot participate in supervised
exercise.
Title The development and pilot randomised controlled trial of a
group education programme for promoting walking in people
with intermittent claudication
Author Garry a teau et al 2017
Method A pilot study was subsequently conducted in which 23 new

patients (Rutherford category 1–3) were randomly assigned to
usual care (control) or usual care plus the education programme.
Outcomes were assessed at baseline and six weeks including
daily steps (tri-axial accelerometer), walking capacity (six-minute
walk test and Gardner treadmill test), and quality of life
(Intermittent Claudication Questionnaire [ICQ]). Exit interviews
were conducted to assess the acceptability and usefulness of the
programme.
Results The results suggest that the education programme is feasible,
acceptable, and potentially useful for improving walking capacity
and quality of life. A fully-powered trial exploring clinical and cost
effectiveness is needed.

Title Effects of buerger exercise on
improving peripheral circulation of the
lower extremities among patient with
type 2 DM
Authour Hanan Saber A. El-Fattah1 , Amal F.
Garas2 , Nawal E. Hanna3 , Naglaa M.
Elsayed4
Method . A non-probability purposive sample
consists of sixty male and female adult
patients with type 2 DM were selected
Result The study findings revealed that the post
intervention mean ABI scores of both
legs (Rt leg =1.097, Lt leg =1.086) were
significantly higher than pre-
intervention scores (Rt leg =.885, Lt leg
=.937) (p=0.001). The use of Buerger
Exercises is effective in improving the
perfusion of lower extremities.
Therefore, it is recommended that
Buerger Exercises can be used

PT management in acute venous
disorders
 Goals
 To relieve pain during inflammatory periode
 To regain functional mobility when the symptoms
subside
 To prevent recurrence of the acute disorder

 Bed rest :
 Elevation
 Foot and leg exercises
 Compression
 Ambulation : graded ambulation with legs wrapped
in elastic bandages or when pressure gradient
support stockings are worn can regain functional
mobility

Prevention of venous thrombosis
 Risk can be minimized by:

 The postoperative patients or inpatient confined to
bed with a cradle under leg clothes ,leg can be
elevated periodically
 Active pumping exerecise
 Active or mild resistive R.O.M exercise to both lower
extremities
 Early ambulation
 General breathing exercise

Title Study of the effect of simple exercise with or without
physiotherapy on prevention of deep vein thrombosis
among postmenopausal women requiring CABG
author Khosrow hashemzadeh ,2021

method This quasi experimental study was carried out 34 patients in
tabriz shahid madani hospital.the participants were selected
based on simple random sampling .the experimental group
(N=17)did cardiovascular exercise for 40 min the day before
surgery .other group received physiotherapy for each leg for 15
minutes
Results The results of intragroup DVT and blood tests before and after
the intervention revealed a statistically significant difference in
terms of complete blood count,hemoglobin and hematocrit
(p>0.11)

Title Effect of Neuromuscular Electrical Stimulation on Varicose Veins
in Postpartum Women
Author Volume 88, , December 2020,

ALAA K. ABU ELYAZED, M.Sc.; AZZA B. NASHED, Ph.D.;
Method thirty post-partum women com-plaining from varicose veins

participated in this study. They were randomly distributed in two
equal groups; Group A (control group): 15 women received a life style
modification and advices and Group B (study group): 15 women
received a life style modification and advices in addition to
neuromus-cular electrical stimulation therapy 3 sessions per week for
4 weeks. Doppler ultrasound device for recording peak pop-liteal
vein velocity and the Chronic Venous Disease Quality of Life
Questionnaire (CIVIQ-20) for quality of life were used for assessment
before and after treatment period.
Results results revealed that there was clinical difference and high percent of
improvement in favor of group B (study group) than group A (control
group) regarding both popliteal peak velocity and quality of life
questionnaire CIVIQ-20.

Title Commentary on “Randomised Controlled Trial: Potential Benefit of a
Footplate Neuromuscular Electrical Stimulation Device in Patients with
Chronic Venous Disease”
Author S.K. Kakkos

I.A. Tsolakis
Open ArchivePublished:November 16, 2016DOI:https://doi.org
/10.1016/j.ejvs.2016.10.021
PlumX Metrics
Method a pilot randomised controlled study that investigated the effect of a

footplate NMES device on venous flow parameters, limb oedema and
quality of life outcome measures in 22 patients with CEAP clinical class
C2–C4 CVD over a 6 week period.
Results authors observed a significant difference in the percentage change in

femoral vein flow parameters between the NMES group and a sham
group while using the device, and also a significant increase in limb
volume in the sham group, which was prevented in the NMES group.
Additionally, there was a significant decrease in the Aberdeen Varicose
Vein Questionnaire score in favour of the NMES group during the study,
indicative of an improvement in one or more domains describing the
frequency and severity of pain and other venous symptoms, and also the
interference of varicose veins with work and leisure activities.
Physiotherapy management of
lymphedema
 Goals :
 To reduce lymphedema
 To prevent further edema
 To achieve mechanical reduction and maintenance
of limb size
 To alleviate the symptoms arising from
lymphedema
 Education about preventing infection and cellulitis

Techniques

 Faradism under pressure
 Heat therapy : hot water immersion,microwave and
electromegnatic irridiation to reduce leg volume
and improve skin tonometry
 Other exercises :exercise are performed while
wearing a compressive garments or bandages ,often
with the limb elevated
 Bicycling,strengthning exercises

Combined physical decongestive
therapy
Components Subcomponents
elevation
Lymphatic drainage Manual (by therapist)
Self (by care taker)
Compression Compressive bandage
Compressive garments
Pneumatic compression pump
exercises Isotonic or pumping ,or decongestive exercises
Isometric exercise
Deep breathing ex
Relaxation ex
Mild resisted ex
Cardiovascular conditioning exercise
Skin hygiene Skin care
Prevention of infection

Pneumatic compression therapy
 Pneumatic compression is a therapeutic technique

used in medical devices that include an air pump
and inflatable auxillary sleeves, gloves or boots in a
system designed to improve venous circulation

Mode of treatment In patient ,out patient or home base program
Assessment Figure of eight method
Preparation The limb to be treated completely bared. any
rings ,bracelets ,watch ,splint must be removed the limb is
placed in a cotton gauze sleeve before being put into the
compressive sleeve .the sleeve is then connected by
plastic /rubber tubing to the machine
duration 3 session of 3 hours each for 5-14 days

Manual lymphatic drainage
 A series of pumping and stretching hand

movements in a range of sequences are used to
move the skin in a specific directions based on the
underlying structure and physiology of lymphatic
system

Techniques
1)stationary circle
2)rotatory technique
3)pump technique
4)scoop technique

Prevention of lymphedema
• avoid static ,dependent positioning of the lower

extremity, such as prolong sitting or standing
• elevate involved limbs and perform repetative
pumping exercise frequently during the day
• wear compressive garments while exercising
• Avoid wearing clothing that restricts circulation,
such as sleeves or socks with tight elastic bands

Title Far infrared radiation thermotherapy improves tissue fibrosis in
chronic extremity Lymphedema
Author &publication Lymphatic reserch and biology 16(3) 2018
Method Patients accepted only FIRT for a total of 20 sessions .treatment session
duration was 2 hours and a stable machine temperature 42’C was
maintained throught treatments .clinical outcome measures included
circumference of affected extremity ,subjective assessment, and quality
of life .laboratory outcome measures included serum and local
lymphedema tissue fluid concentrations of fibrosis associated cytokines
Results After the treatment skin elasticity of the affected extremity improved
significantly (p<0.05). Laboratory results revealed a significant decreases
in local tissue fluid concentration of TGF-b1(p=0.o41 and IL-18
(p=0.049)after course complition
Title Comprehensive Decongestive Therapy as a Treatment for Secondary
Lymphedema of the Lower Extremity and Quality of Life of Women After
Gynecological Cancer Surgery
Author Lucia Kendrová,1,A,B,C,D,E,F,G Wioletta Mikuľáková,1,A,B,E,G Katarína Urbanová

,1,B,E,F Štefánia Andraščíková,2,C,D,G Silvia Žultáková,2,E,F,G Peter Takáč,3,C,D,E and
Yuriy Peresta1 2020
Method 50 patients diagnosed with secondary lymphedema of the lower extremities
after gynecological cancer followed by radiotherapy included During
therapy, we applied manual lymphatic drainage, instrumental lymphatic
drainage, multilayer bandage, vascular gymnastics (with loaded external
compression), hydrotherapy, and patient education on the adjustment
necessary for a life-long regimen. The circumference of the limb was
measured using the Kuhnkes disk method, QoL was assessed using the
LYMQOL LEG questionnaire, and for assessment of pain the Visual Analogue
Scale (VAS) was used.
Results After treatment, we found a reduction in lymphedema (P<0.001), an increase
in QoL (P<0.001), and a reduction in pain (P<0.001). We found a significant
relationship between QoL change and pain in the domains of symptoms,
function, and overall QoL (P<0.005). The results showed that reduction of
lymphedema was not a significant predictor of QoL (P>0.001).

Title Effects of Intermittent Pneumatic Compression on Lower Limb
Lymphedema in Patients with Type 2 Diabetes Mellitus: A Pilot
Randomized Controlled Trial
Author Alessandro de Sire,Maria Teresa Inzitari,2021

1
mathod Adults with a clinical diagnosis of T2DM and lower limb

lymphedema (stage II–IV) were recruited from July to December
2020. Study participants were randomized into two groups:
experimental group, undergoing a 1-month rehabilitative program
consisting of MLD and IPC (with a compression of 60 to 80 mmHg);
control group, undergoing MLD and a sham IPC (with compression
of <30 mmHg). The primary outcome was the lower limb
lymphedema reduction, assessed by the circumferential method
(CM). Secondary outcomes were: passive range of motion (pROM)
of hip, knee, and ankle; quality of life; laboratory exams as fasting
plasma glucose and HbA1c
result Out of 66 T2DM patients recruited, only 30 respected the eligibility

criteria and were randomly allocated into 2 groups: experimental
group (n = 15; mean age: 54.2 ± 4.9 years) and control group (n = 15;
mean age: 54.0 ± 5.5 years). At the intra-group analysis, the
experimental group showed a statistically significant improvement
of all outcome measures (p < 0.05). The between-group analysis
showed a statistically significant improvement in pROM
Title Physical therapy enhances functions and quality of life in older
patient with breast cancer related lymphedema – experimental
exercise
Author A kostanoglu ,E taract 2021
Method 68 patients who had BCRL were inluded arm function was
evaluated with the constant –murely scale ,while ADL was
measured with the lymphedema was measured with the Lawton
Instrumental Activities of Daily Living Scale, and QoL was
measured with the Lymphedema Functioning, Disability and
Health Questionnaire as pre‑ and post‑treatment tests. The
patients underwent a CDPt program for 6 weeks.
Results There were statistically significant improvements for all outcome
measurements in older patients with Grade 1 and 2 lymphedemas
after the treatment (P < 0.001). The Grade 1 patients had a greater
difference at mobility, participation in the life and social activities,
and their total scores of quality of life had a significance level of P
< 0.001.


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VASCULAR DISORDERS AND

By: Jyoti Makwana

•Blood and lymph flows through

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

 Compliance of the blood vessels

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

 Windkessel vessels are the aorta and its major

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

 capillaries were diameter is small the velocity can be

 This can cease blood flow in the capillaries

 Fahraeus-linqvist effect blood flow is still possible

 Causes of this effect is axial streaming

Vascular rehabilitation,subin solomen ,5th edition kishner

 This phenomenon is called axial streaming

 Small branches divide from these large branches

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

•Artery have three layered walls that

•The walls of the artery are generally

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

 The two primary function of the lymphetic system

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

Acute arterial occlusion •Thrombophlebitis

Vascular rehabilitation,subin solomen ,5th edition

Acute Superficial venous

Vascular rehabilitation,subin solomen ,5th edition kishner

• the PVD is a major cause of morbidity and mortality in

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

II a. Mild claudication 2. Moderate claudication

claudication 5. Minor tissue loss

IV. Ulceration or gangrene

Vascular rehabilitation,subin solomen ,5th edition kishner

•it is a general term used to include

Vascular rehabilitation,subin solomen ,5th edition kishner

hypertensive Monk berg atherosclerosis

hyaline hyperplasic necrotizing

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

 Permeability of the vessel wall is increased in

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner

 Systemic hypertension , which results in endothelial

Vascular rehabilitation,subin solomen ,5th edition kishner

 Necrotizing arteriolitis is a form of hyaline

Vascular rehabilitation,subin solomen ,5th edition kishner

 Monkeberg arteriosclerosis is the calcification of

 Age related degenerative process

Vascular rehabilitation,subin solomen ,5th edition kishner

• Deposition of calcium salts in the media produces

Vascular rehabilitation,subin solomen ,5th edition kishner

Vascular rehabilitation,subin solomen ,5th edition kishner