This document provides information on cardiac rehabilitation considerations for patients with peripheral vascular disease (PVD). It discusses the types and causes of PVD, risk factors, clinical manifestations, diagnosis, complications, and management. For cardiac rehabilitation, it recommends supervised treadmill exercise 3 times per week at a moderate intensity that brings on claudication pain within 3-5 minutes. The goals are to improve walking distance and capacity. Home-based walking with behavioral techniques can also be effective. Upper body ergometry, resistance training, and lifestyle risk factor management are complementary. Regular lifelong maintenance exercise is encouraged to prevent disability from PVD.

1. JAMIA MILLIA ISLAMIA
Topic: cardiac rehabilitation consideration
for patient with PVD
CENTER OF PHYSIOTHERAPY AND REHABILITATION SCIENCES
Physiotherapy in cardiopulmonary conditions (402)
Submitted to: DR. Jamal Ali Moiz
Submitted by: Nada Zareen
BPT 4th year
ROLL NO. : 17BPT042
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2. Introduction
• Peripheral vascular disease (PVD) is a slow and progressive circulation
disorder. Narrowing, blockage, or spasms in a blood vessel can cause PVD.
• It is characterised by a reduction in blood flow and hence oxygen through
the peripheral vessels. When need of the tissues for oxygen exceeds the
supply, areas of ischemia and necrosis is develops.
• PVD may affect any blood vessel outside of the heart including the
arteries, veins, or lymphatic vessels. Organs supplied by these vessels,
such as the brain, and legs, may not get enough blood flow for proper
function. However, the legs and feet are most commonly affected.
• Peripheral vascular disease is also called peripheral arterial disease.
• PVD is also known as
– arteriosclerosis obliterans
– arterial insufficiency of the legs
– claudication
– intermittent claudication
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3. 1. Arterial insufficiency
• There decreased blood flow towards the tissues, producing ischemia
• Pulses are usually deminished or absent
• Sharp, stabbing pain occurs because of the ischemia, particulary with activity
• There is interference with nutrients and oxygen arriving to the tissues, leading to
ischemic ulcers and changes in the skin.
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4. 2. Venous insufficiency
• There is decreased return of blood from the tissues to the heart
• Leads to venous congestion and stasis of blood
• Pulses are present
• Lead to edema, skin changes and stasis ulcers
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5. Comparison of characteristics of
arterial and venous disease
Arterial disease Venous disease
skin Cool or cold, hairless, dry,
shiny, pallor on elevation
and rubor on dangling
Warm, though, thickened,
mottled, pigmented areas
pain Sharp, stabbing, worsen
with activity and walking,
lowering feet may relief
pain
Aching, cramping activity
and walking some time help,
elevating feet help reduce
pain
ulcers Severely painful, pale, gray
base, found on heel, toes,
dorsum of foot
Moderately painful, pink
base, found on medial
aspects of the ankle
Pulse Often absent or dimineshed Usually present
edema infrequent Frequent especially at the
end of the day and in area of
ulceration 5

6. Types of peripheral vascular disease
• There are two main types of PVD:
• Organic PVD results from changes in the blood vessels caused by inflammation,
plaque buildup, or tissue damage. Example atheroscelerosis.
• Functional PVD happens when blood flow decreases in response to something that
causes the blood vessels to vary in size, such as brain signals or changes in body
temperature. In functional PVD, there is no physical damage to the blood vessels.
Example Raynuad’s syndrome.
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7. Causes
1. Organic PVD
• smoking
• high blood pressure
• diabetes
• high cholesterol
Additional causes of organic PVD include
• extreme injuries,
• muscles or ligaments with abnormal structures,
• blood vessel inflammation,
• infection.
2. Functional PVD
• emotional stress
• cold temperatures
• operating vibrating machinery or tools
• Drugs
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8. Risk factors
NON MODIFIABLE Risk factors:
• Age (especially older than age 50)
• History of heart disease
• Male gender
• Postmenopausal women
• Family history of high cholesterol, high blood pressure, or peripheral vascular
disease
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9. MODIFIABLE Risk factors :
• Coronary artery disease
• Diabetes
• High cholesterol
• High blood pressure
• Overweight
• Physical inactivity
• Smoking or use of tobacco products
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10. Clinical manifestation
• Intermitted claudication- most common
– Pain on the extremity that develops in the muscle that has an inadequate blood
supply during exercise
– The cramping pain disappear within 1-2 minute after stopping the exercise or
resting
– The femoral artery is often affected – pain the calf muscle- common symptom
• Pain at rest indicative of severe disease
– Gnawing, burning pain, occur more frequently at night
• Feeling of coldness
• Numbness
• Tingling sensation
• In Advanced aterioscelorosis oblitrans- ischemia may lead to necrosis, ulcerations
and gangrene- toes and distal foot
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11. Diagnosis
• Angiography
• Ankle-branchial index
• Doppler ultrasound
• MRA
• Treadmill exercise test
• PPG
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12. Complications
• Amputation (loss of a limb)
• Poor wound healing
• Restricted mobility due to pain or discomfort
• Severe pain in the affected extremity
• Stroke (3 times more likely in people with PVD)
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13. Management
Medical management
• cilostazol or pentoxifylline to increase blood flow and relieve symptoms of
claudication
• clopidogrel or daily aspirin to reduce blood clotting
• atorvastatin, simvastatin, or other statins to lower high cholesterol
• angiotensin-converting enzyme (ACE) inhibitors to lower high blood pressure
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14. Surgical management
• Surgical management is used in case of advanced disease- ischemic changes and
pain severely impairs activity
• Embolectomy
• Endarterectomy
• Arterial bypass surgery
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15. Cardiac rehabilitation
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16. Goals of cardiac rehabilitation
1) to reduce limb symptoms;
2) to improve exercise capacity and prevent or lessen physical disability; and
3) to decrease the occurrence of cardiovascular events.
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17. Effects cardiac rehabilitation
• The improvement of the walking distance
• Improve muscular perfusion, by reduction of the endothelial dysfunction,
contributes to the improvement of the oxidative metabolism
• improve daily activities
• reduction of cardiovascular risk factors,
• 30% mean decrease of mortality
• Improve quality of life
• Helps in mood disorder
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18. Physical assessment
• Inspection:
– thick shiny skin
– Hair loss
• Expose the skin and look for:
– Brittle nails
– Colors changes
– Ulcers
– Muscle wasting
• Palpation:
– Temperature (cool, bilateral/unilateral)
– Pulses
– Capillary refill
– sensation/movement
• Auscultation:
– Femoral bruits
• Ankle brachial index:
– = systolic bp in ankle/systolic bp in brachial artery
• Burger’s test:
– Elevate the leg to 45 degree and look for palor
– Place the leg in dependent position 90 degree and look for red flushed foot
before returning to normal
– Palor at <20 degree represents severe PAD 18

19. Evaluation of the aptitude to exercise
• The measurement of the walking distance on flat ground.
• 6-minute walking test
• Treadmill walking test
• Test on ergometric bicycle
• Stress test with the upper limbs
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20. summarised findings of 2018 cocraine review of the best exercise
prescription for PAD:
• Supervised treadmill exercise improves treadmill walking
performance in patients with PAD.
• Supervised treadmill exercise has greater benefit on treadmill
walking performance than home-based walking exercise.
• Home-based walking exercise interventions that involve behavioral
techniques are effective for functional impairment in people with
PAD and improve the 6-min walk distance more than supervised
treadmill exercise.
• Upper and lower extremity ergometry improve walking performance
in patients with PAD and improve peak oxygen uptake.
• Lower extremity resistance training can improve treadmill walking
performance in PAD, but is not as effective as supervised treadmill
exercise.
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21. • Modality Supervised :Treadmill Walking
• Intensity :40%–60% maximal workload based on baseline treadmill test or
workload that brings on claudication within 3–5 min during a 6-MWT
• Session duration : 30–50 min of intermittent exercise; goal is to accumulate at least
30 min of walking exercise
• Claudication intensity :Moderate to moderate/severe claudication as tolerated
• Work-to-rest ratio :Walking duration should be within 5–10 min to reach moderate
to moderately severe claudication followed by rest until pain has dissipated (2–5
min)
• Frequency :3 times per week supervised
• Program duration :At least 12 wk
• Progression :Every 1–2 wk increase duration of training session to achieve 50 min.
As individuals can walk beyond 10 min without reaching prescribed claudication
level, manipulate grade or speed of exercise prescription to keep the walking bouts
within 5–10 min
• Maintenance: Lifelong maintenance at least 2 times per week
Exercise Prescription for Supervised
Exercise Treadmill Training in Patients
With Claudication
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22. Exercise prescription for PAD patient
without claudication
Endurance Training
• Frequency:3–5 d·wk−1
• Modality:
• Stairclimber
• Stationary Cycle
• Arm Cycle Ergometry
• Rowing
• Swimming
• Intensity:40 – <60% heart rate reserve + resting HR or 40 – <60%
VO2 reserve + resting VO2
• Duration:30–60 min·day
−1
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23. Resistance Training
• Frequency:≥2–3 d·wk
−1
• Intensity:1–3sets of 8–15 RM for muscle group
• All Major Muscle Groups
1. Arms/Shoulders:
• Biceps curls
• Triceps extension
• Overhead press
• Lateral raises
2. Chest/back:
• Bench press
• Lateral pull down /pull-ups
• Bent-over / Seated row
3. Legs:
• Leg extensions, curls, press
• Adductor / Abductor
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24. Biceps curl
Triceps extension
Overhead press
Lateral raises
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25. Bench press Lateral pull up and pull down
Bent over/seated row
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26. Leg extension
Leg curl
Leg press 26

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