Physio

2. PERIPHERAL VASCULAR DISEASE
 Any disorder that interferes with arterial or venous
blood flow of the extremities.
 Peripheral vascular disease includes a group of
diseases in which blood vessels become restricted
or blocked
 Arterial disorder
 Venous disorder

3.  The chance of having PAD increases as you
get older.
 People over age 50 have a higher risk for PAD
and the majority of patients will fall in this
demographic.
 One in 20 adults over age 50 and one in five
over age 70 will have PAD.

4. Arterial disorder
 Fibro muscular dysplasia-
Hyperplasic disorder affecting medium and small
sized arteries.
 More in females and involves renal and carotid
arteries but can affect iliac and subclavian arteries.
 Symptoms: atherosclerosis including claudication
and rest pain.
 “string of beads” appearance.

5.  Thromboanginitis obliterance(Burger’s disease)
 Inflammatory occlusive disorder involving small and
medium sized arteries and veins in distal upper and
lower extremities.
 Cerebral, visceral and coronary vessels may also be
involved.
 More in men under age 40.
 Cause is unknown, but shows a definite relationship
with cigarette smoking.

7.  Acute arterial occlusion
 Sudden cessation of blood flow to an extremity.
 Severity of ischemia depend on location and extent
of the occlusion and presence of collateral blood
vessels.
 causes:- embolism and thrombus

8.  Embolism causes- Cardiac disorders include atrial
fibrillation, Myocardial infarction, ventricular
aneurysm.
 Emboli may lodge in femoral , iliac , aorta ,
popliteal and tibioperoneal arteries.
 Thrombosis causes- trauma, thoracic outlet
compression syndrome and entrapment of popliteal
artery.
 Thrombosis most frequently occurs in
atherosclerotic vessels.

9.  Clinical fearture- pain, paresthesia,
numbness, and coldness occur within 1 hr.
Paralysis with severe ischemia. loss of pulses
distal to occlusion, cyanosis, decreases skin
temp, mottling, muscle stiffening, loss of
sensation, weakness, and absent deep
tendon reflexes.

11.  Atheroembolism
 Emboli lodge in small vessels and may not occlude
large vessels so distal pulses remain palpable.
 Clinical feature: pain, tenderness at the site of
embolism.
 “Blue toe” syndrome, necrosis, gangrene, pallor,
livedo reticularis.

13.  Reynaud's’ phenomenon
 Episodic digital ischemia, digital blanching, cyanosis
and rubor of fingers or toes following cold exposure
and subsequent rewarming.
 One or more digits will appear white when exposed
to cold environment.

14.  Acrocyanosis
 Arterial vasoconstriction and secondary dilation of the
capillaries and venules with resulting persistent
cyanosis of hand and less frequently feet.
 Female > Male
 age of onset <30yrs
 Normal pulses, peripheral cyanosis and moist palms
 Distinguish from Reynaud's phenomenon:-It is persistent
and not episodic and blanching doesn’t occur.

16. Venous disorder
 Venous thrombosis(thrombophlebitis)
 Presence of thrombus within superficial or deep
vein and that accompany inflammatory response in
the vessel wall.
 Prevalence- 50% pts with orthopedic surgical
procedure, 10-40% pts with abdominal or thoracic
surgeries.

17.  Deep vein thrombosis
 Most imp consequences of this disorder are
pulmonary embolism and chronic venous
insufficiency.
 More in lower extremity than upper extremity.

18.  DVT of iliac, femoral and popliteal veins is
suggested by leg swelling, warmth,
erythema.
 Examination:- post calf tenderness, warmth,
increased tissue turger or modest swelling
and Homans’s sign(unreliable).

19.  Superficial vein thrombosis
 Associated with i.v catheters and infusion, occures
in varicose veins, thromboangitis obliterans.
 Clinical feature: pain at localized to the site of
thrombus.

20.  Varicose vein
 Dilated, tortuous superficial veins results from
defective structure and function of the valves of
the saphenous veins, from weakness of the vein
wall, from high luminal pressure
 Clinical feature:- dull ache, mild ankle oedema
which is relieved with leg elevation.

22.  Chronic venous insufficiency
 May result from deep vein thrombosis and/or
valvular incompetence.
 Valves become thickened and contracted, veins
become rigid and thick-walled.

23.  Clinical feature: dull ache on long standing,
relieved by leg elevation.
 Erythema, dermatitis and hyper
pigmentation develops along distal aspect of
leg, skin ulceration occur near the medial
and lateral malleoli

26.  Smoking
 Hypertension
 Diabetes mellitus
 Dyslipidemia
 Thrombosis formation

27. Arterial ulcerations Venous ulcerations
Arterial disease refers to a
lack of adequate blood
flow to a region or regions
of the body.
Venous insuffiency is inadequate
drainage of venous blood from a body
part usually results in edema.
Etiology Thrombosis, embolism,
cigarette smoking
valvular incompetence
Incidence Less as compare to venous
ulcers
Much higher then arterial ulcers
age older older
Location Most frequently located on
the LE : lateral malleoli,
dorsum of feet, toes.
Over pressure point.
Greator area of the leg
Common site is medial aspect.
Clinical
feature
Claudication , rest pain,
paresthesia, numbness,
 complain of minor dull leg pain,
 Swelling of unilateral or bilateral LE
Arterial insufficiency Venous insuffiency

28. clinical feature
and coldness occur within 1 hr
after physical activity Paralysis
with severe ischemia.
 Trophic changes : abnormal
nail growth, dry skin , decrease
leg and foot hair.
complain of itching,
fatigue, aching, heaviness in
involved limb,
 increase in skin
temperature of lower leg
 tissue is wet from a
typically large amount of
draining exudates
Risk factors Diabeties
Hypertension
Smoking
Obesity
Inability to elevate limb
Previous history of vascular
disease.
Previous history of dvt
Varicose vein
Traumatic injury to lower leg
Obesity
pregnency
pain Itnermittent claudication
Can be worstat night and at rest
Improves with dependency
Throbing,aching, heavy
feelings in leg
Improves with elevation and
rest.

29. Ulcers characteristics Punched out ,
occasionally deep
Iregular in shape
Unhealhy appearnace of
wound bed
Presence of necrotic
tissue
Low exudate
Shallow with flat margin
Modarate to heavy
exucate
Often presents with
slough at the base with
granulation tissue
Condition of the lower leg Thin , shiny dry skin
Reduce or no hair on
lower leg
Skin feels cooler to
touch
Pallor on leg elevation
Abusence or weak pedal
pulses
Delayed
cappilary(greater tehn 3
sec)
Development of
gangrene
Haemosistin staining
Thickening and fibrosis
Dilated veins at the
ankle
Eczematous itchy skin
Pedal pulses present
Normal capillar
refill(less then 3 sec)
Limb oedema is
common.

30. Tests and measurements Ankle- brachial Index(ABI)
Healing will be impaired
and compression may be
contraindicated
Skin temperature of the
lower leg may be elevated
Existing edema may
decreases with elevation
Intervention  Facilitate superficial
blood flow to target tissue.
 Prevention of smoking
 Weight control
 Improvement of
collateral circulation
 Management of
hypertension
 Compression bandaging
and garments,
 gait training ,
 Range of motion
exercises

31.  Severity of peripheral vascular disease
 Fontaine classification
stages symptoms
I Asymptomatic
II Intermittent claudication
IIa Pain-free, claudication walking >200 m
IIb Pain-free, claudication walking <200 m
III Rest/nocturnal pain
IV Necrosis/gangrene

32.  Rutherford classification
STAGES DESCRIPTION
Stage 0 Asymptomatic
Stage 1 Mild claudication
Stages 2 Moderate claudication
Stage 3 Severe claudication
Stage 4 Rest pain
Stage 5 Ischemic ulceration not exceeding ulcer of the digits of the
foot
Stage 6 Severe ischemic ulcers or frank gangrene

33.  Ankle brachial index
 Pulse examination.
 Treadmill exercise testing
 CT angiography
 MR angiography

34.  Used to examine the vascular system.
 Provide information about the potential loss
of perfusion in L.Es
 Performed with DOPPLER ultrasound.
 Brachial ,radial, femoral, popliteal, dorsalis
pedis, and posterior tibialis.

35. In following conditions ABI should be used:-
Exertional leg pain
Non-healing wound
Patients with 50 yrs and older with a
history of smoking or diabetes

36. It provide information about possible vascular
system involvement.
Pulse scale:-
0 =no pulse
1+ =weak pulse, difficult to palpate
2+ =palpable but not normal, diminished
3+ =normal, easy to palpate
4+ =bounding, very strong

37.  primary objectives are to obtain reliable
measures of:
1) the rate of claudication pain development,
2) The ABI response to exercise,
3) the presence of coexisting coronary heart
disease.
 The test should be progressive with gradual
increments in grade
 A highly reliable treadmill test for patients
with PAD uses a constant walking speed of 2
mph and gradual increases in grade of 2%
every 2 minutes beginning at 0% grade

38.  Functional claudication distance: a reliable and
valid measurement to assess functional
limitation in patients with intermittent
claudication Lotte M Kruidenier1, Saskia PA
Nicolaï1, BMC Cardiovascular Disorders 2009,
9:9
 Disease severity and functional impairment in
patients with intermittent claudication is usually
quantified by the measurement of pain-free
walking distance (intermittent claudication
distance, ICD) and maximal walking distance
(absolute claudication distance, ACD).
 However, the distance at which a patient would
prefer to stop because of claudication pain
seems a definition that is more correspondent
with the actual daily life walking distance.

39.  A study is conducted in which the distance a
patient prefers to stop was defined as the
functional claudication distance (FCD), and
estimated the reliability and validity of this
measurement.
 FCD is a reliable and valid measurement for
determining functional capacity in trained
patients with intermittent claudication.
Furthermore it seems that FCD better reflects
the actual functional impairment.

40.  By using this treadmill protocol, typical
distances to the onset of pain and the
maximal claudication pain are approximately
170 m (3 minutes) and 360 m (6.5 minutes),
respectively.
 Measurement of the ABI immediately after a
treadmill exercise stress test can help diagnose
PAD in difficult cases and determine the extent
of impairment of the peripheral circulation.

41.  Exercise increases systemic blood pressure (ie,
the brachial pressure), whereas pressure distal
to an arterial lesion in the lower extremity falls
with exercise as a consequence of dilation of
secondary arterioles.
 As a result, ABI typically drops from a resting
value of 0.7 to approximately 0.3 immediately
following the treadmill test.
 The sensitivity of ABI measured after treadmill
walking is more than 95%.

42.  CT Angiography is done when MRA is
contraindicated to patients.
 Done in patient with endovascular
intervention, surgical bypass and to select
sites of surgical anastomosis.

43.  Visual analogue scale(VAS)
 Walking impairment questionnaire(WIQ)
 Claudication pain scale(CLAU-S)
 Short form 36(SF-36)

44.  Claudication distances and the Walking
Impairment Questionnaire best describe
the ambulatory limitations in patients
with symptomatic peripheral arterial
disease Sara A. Myers, ( J Vasc Surg
2008;47:550-5.)
 Qualitative measurements
 Quantitative measurements

45.  Qualitative measurements included
• Walking Impairment Questionnaire (WIQ) and
• Medical Outcomes Study Short Form-36 (SF-36)
Health Survey
 Quantitative evaluation outcome measures
included
• Ankle-brachial index,
• Iinitial claudication distance,
• Absolute claudication distance, and
• Self-selected treadmill pace.

46.  The WIQ is a disease-specific
questionnaire validated in patients with
intermittent claudication.
 It consists of four subcategories:
• pain,
• distance,
• walking speed, and
• stair climbing.

47.  Eight health domains are assessed with
the SF-36:
 Physical Function,
 limitation due to Physical Health,
 limitation due to Emotional Problems,
 Energy,
 Mental Health,
 Bodily Pain,
 General Health, and
 Social Function.

48.  The WIQ and SF-36 both use a scale from 0 to
100,with a score of 0 representing the low score
and 100 being the high score.
 data demonstrated that absolute and initial
claudication distances, and WIQ pain, speed, and
distance subscales are the measures with the
best ability to describe the ambulatory
limitation of claudication patients and also
closely relate to their QOL

49. Claudication-Scale is a
disease-specific quality
of life (QoL) scale for
patients with
intermittent claudication
due to peripheral arterial
disease of the lower
limbs.

50.  RUBOR OF DEPENDENCY
non invasive test to examine the LE for
the presence of ischemia.
Following elevation of limb,lowering of
limb should return the skin of the limb to
a pink colour. If the colour is dark red and
takes more then 30seconds to appear—
the test is +ve arterial insufficiency.

51. TRANSCUTANEOUS OXYGEN- non-invasive
method
 Measurement of O2 at skin level gives
information about what is happening at
cellular level.
 Result predictive for healing of ulcers and
amputation wounds.
 Used primarily for research purpose
because time consuming.

52.  Air plethysmography
A non invasive test of both arterial and venous
circulation. Changes in leg volume are measured
using a pressure cuff that quantifies volume
changes during rest, standing, and light walking,
venous obstruction and arterial inflow can be
observed with this test.
o Venous filling time
the extremity is elevated and then lowered in
to a dependent position. The time it takes for
the veins on top of the foot to refill is recorded.
Normal filling time is 15 sec. greater then 15 sec
indicates arterial disease while less then 5 sec
indicates venous disease.

53. Neurological
 Spinal canal stenosis
 >50 yrs
 Proximal location
 Initially lumber and
buttocks then radiates
distally
 Weakness, burning,
numbness and tingling
 Worse walking up or
downhill, or prolonged
standing relief by lying
down or flexing supine
takes 20 to 30 mins
 Bowel and bladder can be
affected
Vascular
 Aortoilliac arterial occlusive
disease
 >50yrs
 Distal location, calf ,thigh
 Radiates proximally
 Cramping aching squeezing
 Walking a set distance each
time, especially uphill
 Relief with standing still-
fast
 Slow walking decreases
severity
 Associated impotence

54.  Pharmacological therapy
 Smoking cessation
 Exercise therapy

55. Algorithm for the evaluation and management of patients with peripheral arterial
disease. (MWD = maximal walking distance; PFWD = pain-free walking distance; SF-
36 = medical outcomes short form 36 questionnaire; WIQ = walking impairment
questionnaire; A1c = hemoglobin A1c; JNC-VI = Sixth report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure; LDL = low-density lipoprotein; MRA = magnetic resonance angiography)

56. Drugs Dosage comments
Cilostazol (Pletal) 100 mg twice per day
orally
Correct dosing is
critical; avoid in
patients with heart
failure; may cause loose
stools and gastric upset
Pentoxifylline (Trental) 400 mg 3times per day May have a small effect
on walking ability,
Aspirin 75to 325 mg per day
orally
reduce risk of MI,
stroke, vascular death
Clopidogrel (Plavix) 75 mg per day orally Fewer side effects than
aspirin .
Pharmacological Therapy

57.  Smoking cessation reduces severity of
claudication .In some studies it shows in an
increase in walking time.
 Smoking cessation reduces progression of this
disease.
 It also reduces risk of MI and death due to other
vascular disease.
 Two approaches have strong evidence of efficacy
for smoking cessation
i. Counselling
ii. Pharmacotherapy
Both above significantly increased the rate of
smoking cessation at 6 month compared with
verbal advice to quit smoking.

58.  exercise program is the most effective
treatment of PAD. Exercise increased the
distance to onset of claudication.
 Improvements in walking ability occur when
• Each exercise session lasts longer than 30
minutes,
• sessions take place at least three times per
week,
• when the patient walks until near-maximal
pain is reached in each session, and
• when the program lasts at least six months.

59.  The American Heart Association and American
College of Cardiology (AHA/ACC) Guidelines for
the Management of Patients With Lower
Extremity Peripheral Arterial Disease (Physical
Therapy July 2011 vol. 91 no. 7 997-1002 )
recommend the following key elements of an
exercise program for patients with IC
• Supervised treadmill or track walking at an
intensity that elicits claudication symptoms
within 3 to 5 minutes (a score of 1 on the
Claudication Pain Rating Scale)

60. • Walking until the claudication pain is rated as
moderate (a score of 2 on the Claudication Pain
Rating Scale), followed by standing or sitting rest
to permit symptoms to resolve.
• Repeating these exercise and rest cycles for 35
minutes of intermittent walking.
• Increasing the exercise program by 5 minutes
per session to 50 minutes, 3 to 5 times per week,
for a minimum of 12 weeks.

61. Exercise
component
Comment
Frequency Three exercise sessions per wk
Intensity Initially, 50% of peak exercise capacity,
with gradual progression to 80% by
the end of the program
duration Initially, 15 min of exercise per session,
with gradual progression to 40 to 50
min by the end of the program
mode Weight bearing (eg, walking, stair
climbing); non–weight-bearing tasks
(eg, bicycling) may be used for
warming up and cooling down
Type of
exercise
Intermittent walking to a claudication
pain score of 3 using a 4-point pain
scale
Programme
length
Approximately 6 months

62.  Mediators and Readiness to Exercise in Patients
at Risk of Symptomatic Peripheral Arterial
Disease.(angiology 2010)
 Adults aged 65 years and older are the fastest
growing group in the United States and have the
lowest level of activity. While time is a major
barrier to exercise for younger adults, older cite
poor health as the most common barrier, along
with Pain.
Walking is a well-accepted form of exercise.
 Efficacy of arm-ergometry versus treadmill
exercise training to improve walking distance
in patients with claudication. (Vasc Med 2009)
 The efficacy of treadmill walking training to
improve pain-free (PFWD) and maximal (MWD)
walking distance in patients with claudication is
well documented.

64.  The data from this study demonstrate for the
first time that dynamic arm exercise training
can improve walking capacity in people with
PAD induced claudication compared to
participants receiving usual care, and
improvement was not different from that
seen in response to treadmill walking
exercise training.
 Effects of a long-term exercise program on
lower limb mobility, physiological responses,
walking performance, and physical activity
levels in patients with peripheral arterial
disease(J Vasc Surg 2008)
 The results of this study confirm that a 12-
month supervised exercise program will
result in improved walking performance, but
does not have an impact on lower limb
mobility, peak physiological responses, or
physical activity levels of PAD-IC patients.

65.  Patients With Peripheral Artery Disease Who
Complete 12-Week Supervised Exercise
Training Program Show Reduced Cardiovascular
Mortality and Morbidity(Circ J 2009)
 Supervised exercise training improved cardiovascular
mortality and morbidity in patients with PAD, which
suggests that exercise training should be considered
as a secondary prevention strategy for these patients
 The development and implementation of a
regional network of physiotherapists for
exercise therapy in patients with peripheral
arterial disease (12 July 2005 BMC Health
Services Research 2005,)
 This preliminary report describes the
development and implementation of the
Network Exercise Therapy Parkstad. The main
goal of this regional network was to improve the
access to care, and the communication between
the different care providers.

66.  The Importance of Conservative Measures
in Peripheral Arterial DISEASE(AngiologyVolume
59 Number 5 October/November 2008)
 Conservative measures (smoking cessation,
adoption of a regular exercise program,
management of dyslipidemia, strict
glycemic control, antihypertensive, and
antiplatelet treatment) comprise the
mainstay of the therapeutic approach of
patients with PAD.
 Cost–effectiveness of exercise training to
improve claudication symptoms in patients
with peripheral arterial disease. vascular
medicine 2004;9:279-285
 Exercise rehabilitation at 6mths is more
effective and cost less than
PTA(percutaneous transluminal angioplasty),
and its cost saving.

67. Optimizing supervised exercise therapy for
patients with intermittent claudication Journal of
Vascular Surgery 2010
A SET programs consisting of at least 2 training
sessions a week, each lasting over 30 minutes, should
be offered during the first 3 months of the SET
program to optimize improvement in terms of
maximum walking distance.
Benefits of low intensity pain free treadmill
exercise (LIPFE) on functional capacity of
individuals presenting with intermittent
claudication due to peripheral arterial
disease.(Angiology 2009;60:477 486
LIPFE training is an effective intervention for
individuals presenting with intermittent claudication
in peripheral arterial disease

68.  Physical Therapy Improves Venous
Hemodynamic in Cases of Primary Varicosity:
Results of a Controlled Study Angiology1997
Feb;48(2):157-62
 The combined physical therapy was shown to
be of long-term therapeutic value, improving
venous function and reducing patients'
symptoms. These findings indicate that for
the further development of this combined
treatment regimen it would be useful to
identify the individual factors contributing to
its efficacy and evaluate them separately.

69.  Structured exercise improves calf muscle
pump function in chronic venous
insufficiency: A randomized trial Journal of
Vascular Surgery 2004
 Calf muscle pump function and dynamic calf
muscle strength were improved after a 6-
month program of structured exercise.
Directed physical conditioning of the calf
musculature may prove beneficial for
patients with or without alternative
management options for severe CVI

70.  Comparison of reduction of edema after rest
and after muscle exercises in treatment of
chronic venous insufficiency International
Archives of Medicine 2009
 exercises are more efficient to reduce the
edema of lower limbs than resting in the
Trendelenburg position.