Cardiovascular Flashcards
Arteriosclerosis:
is a generic term used for hardening of arteries and arterioles. May
involve any artery in the body and also may affect arterioles. A degenerative arterial
disease where muscle and elastic tissue of the tunica media are replaced by fibrous
tissue. The arterial walls become thickened, hard, and lose elasticity.
Atherosclerosis:
s a multifactorial disease of arteries
affected by atheromas. Affects only the aorta and its
major branches. Abnormal masses of lipids, complex
carbohydrates, blood and blood products, fibrous
tissue and calcium deposits in the tunica intima of
arteries not arterioles. Note: arteriosclerosis and
atherosclerosis often co-exist.
Coronary atherosclerosis:
degeneration of coronary
arteries with gradual decrease of the lumen (e.g. increased
fibrotic tissue, decreased elastic tissue; thrombus may
develop).
Atherosclerosis/Arteriosclerosis: Sign/Symptom
likely no symptoms present until the vessel is
blocked or narrowed enough to alter blood flow or thrombus/embolism formation.
Arteries in the heart may cause angina or heart attack. Symptoms: chest pain, difficulty
breathing, restlessness, dizziness, anxiety.
Ischemic heart disease:
insufficient coronary blood flow (a.k.a. heart attack,
myocardial infarct = necrosis of part of the heart due to occlusion of the coronary
arteries)
Coronary thrombosis:
occlusion of the coronary artery. Very little anastomosis
and/or collateral circulation exists in cardiac muscle.
Arteries that supply head/brain, may experience_______ if embolism occurs
TIA or stroke
weakness, numbness, slurred speech
Arteries in the arms/legs patient may experience pain in arms or legs and ___________ (peripheral vascular disease)
intermittent
claudication
Aneurysm
abnormal dilation of blood vessels. If vessel walls become weakened,
aneurysms may occur – potential to rupture vessel, excessive bleeding and potential
organ damage or fatal. Sudden severe pain in head or abdomen (brain, aorta)
Hypertension:
elevation of systolic and/or diastolic BP, either primary (85% due to
unknown cause) or secondary (15% is secondary to renal disease, adrenal cortical
tumour).
High BP threshold is______ ; “dangerous” is
_______
140/90
160/95
Signs and symptoms
HBP
Asymptomatic until complications develop
Variable depending on organs affected
Dizziness, light-headedness, HA, fatigue, facial flushing and
personality changes can all occur
Possible edema in lower extremities
The cardiovascular system consists of the
heart and blood vessels: arteries, capillaries,
and veins.
It’s estimated there are approximately_______of blood vessels in the
human body.
100,000 km
The cardiovascular “loop” transports
oxygen, nutrients and hormones to each cell
carbon dioxide and metabolic end products out from each cell
Factors that affect the normal function of the heart or blood vessels potentially
predispose the cells to poor nutritional status. Heart disease including:
Angina
Hypertension
Valvular dysfunction
diseases of the vasculature that compromise tissue health such as:
Arteriosclerosis
Atherosclerosis
The massage therapist treating a patient/client/guest with a cardiovascular
dysfunction has many challenges. Techniques and modalities used should not:
Increase the work of the heart: e.g. by dramatically increasing venous return
Increase the risk of local tissue damage: e.g. XFF can cause prolonged bleeding in
malnourished tissue
Interact with the use of medications: e.g. vasodilators and hydrotherapy
Increase the risk of a secondary systemic complication: e.g. dislodging a thrombus
Cardiovascular Conditions: History:
Diet, health habits, medications, recent MD visits, fitness level,
general health, pain at rest, intermittent claudication, ask about
respiratory status
Cardiovascular Conditions: Observation:
Edema, varicosities, facial colorations, extremity
coloration (skin color: flushing, cyanosis/grey/white caused by poor
arterial supply or hypoxia). Dyspnea caused by pulmonary edema
resulting in labored or difficult breathing – may be related to cardiac
insufficency
Cardiovascular Conditions: Palpation:
Pulses – assess if they are normal, absent, dimished,
bounding (compare bilaterally). Bradycardia (decreased) or tachycardia
(increased), temperature of extremities and core, clamminess and
sweating due to sympathetic/reflexive changes, edema (pitting vs non
pitting)
Cardiovascular Conditions: Movements:
may assess intermittent claudication if client can not tell
you
Cardiovascular Conditions: Neurological:
TOS
Cardiovascular Conditions:
Referred Pain:
MI refers to shoulder, down arm and can along back and
sternum. Trigger points can also refer to these areas (pec mj/mn,
serratus anterior, scalene, levator scapula etc)
Special tests:
Central cardiovascular: blood pressure, respiratory status,
Peripheral vascular: capillary refill test, allen’s test, manual
compression test, pulses, leg raise for varicose veins, pitted edema test,
homan’s test
How to find pulses:
Use the ___ of your finger, not the____ . Don’t push _____ or you can _____
the vessel.
pad /tip
too hard/occlude
(Sometimes, using a number of fingers along the
course of a vessel, and applying firmer pressure with the distal fingers
will allow you to feel the pulse better in the proximal fingers. It also
may help to use on hand to feel a pulse that’s easy to find while using
the other hand to find the harder one)
Compare pulses _______.
bilaterally
To record pulses:
“____” if strong,
“_____” if weak,
“_____” if absent.
2/2
1/2
0/2
Brachial pulse:
ask pt to flex the elbow to feel the biceps brachii tendon on
the cubital fossa. Apply fingertip pressure on the medial side of the
tendon. The pulse may be more superficial the more proximal you go.
Brachila artery used to be the axillary artery
Radial pulse:
on the lateral side of the wrist, find the bony prominence of the
styloid process . roll your finger medial from this and the artery runs
along the bone. The radial artery is a branch of the brachial artery
Ulnar pulse:
on the medial side of the wrist find the pisiform bone. Roll your
finger laterally from this and the artery runs along here. Harder to find
than the radial artery. This is a branch of the brachial artery.
Femoral pulse:
along the inguinal ligament, about halfway from the ASIS to
the pubic tubercle. Used to be called the iliac artery
Popliteal pulse:
difficult to find – deep. Slightly medial to the center of the
popliteal fossa. Used to be femoral artery
Anterior tibial pulse:
feel along the anterior shin lateral to the tibia. It is
easiest to feel halfway down the shin. Branch of the popliteal artery
Dosalis pedis pulse :
on the top of the foot about 1/3 of the way to the toes,
feel laterally to the extensor hallucis longus tendon. The artery runs
along side the tendon. This is a branch of the popliteal artery.
Posterior tibial pulse :
on the medial side of the ankle find the medial
malleolus. Roll your finger towards the angle of the heel and feel for
the pulse.
Common carotid pulse
only check one at a time. Find the bottom of the
lateral edge of the thyroid cartilage. Then feel 1-2 cm lateral to that
External carotid pulse :
only check one at a time. About 2 cm anterior of the
scm along the fold of the jaw line.
Temporal pulse:
find the top part of the ear that is attached to your face
(about eye level) and about 1 cm anterior is the pulse
What techniques would be safe to perform on a patient with central cardiovascular disease?
MFR depending on tissue health
PROM, Stretches, Joint mobs if indicated
Swedish/petrissage techniques modified to short and segmental strokes
What are red flags to treatment? Consider that pts may be in denial.
Medications
Scarring
Ask about surgical history, family history of cardiovascular disease, risk factors (smoking, lifestyle)
Diseases affecting the blood vessels usually result in some form of
peripheral vascular
disease (PVD).
PVD can affect the
venous or lymphatic circulatory systems.
Occlusive diseases of the blood vessels are a common cause of
disability and usually
occur as a result of ATHEROSCLEROSIS.
Other causes of arterial occlusion include
trauma, thrombus or embolism, vaculitis or vasomotor disorders (Raynaud’s).
THROMBOANGITIS OBLITERANS (BUERGER’S DISEASE):
Inflammatory lesions of the peripheral blood vessels are accompanied by
thrombus formation and vasospasm occluding blood vessels.
A vasculitis, i.e. an inflammatory and thrombotic process, affecting both arteries
and vein, primary in the extremities
Inflammatory lesions of the peripheral are accompanied by THROMBUS
formation and vasospasm occluding and eventually OBLITERATING (destroying)
small and medium vessels of the feet and hands
Cause not known
Demographics- Usually found in men younger than 40 who smoke heavily
THROMBOANGITIS OBLITERANS (BUERGER’S DISEASE):
Symptoms:
Treatment Goals:
Symptoms:
Symptoms are episodic and segmental (i.e. come and go intermittently over time
and appear in different, asymmetrical anatomic locations)
Intermittent claudication in the arch of the foot or the palm of the hand is often the
first symptom
Symptoms include pain at rest, edema, cold sensitivity, rubor (redness of the skin
from dilated capillaries under the skin), cyanosis, and thin, shiny, hairless skin
(trophic changes) from chronic ischemia
Treatment Goals:
Treatment goals include increasing circulation to the hand or foot
BUERGER’S DISEASE
ARTERIOSCLEROSIS OBLITERANS:
Definition:
Proliferation of the intima causes complete obliteration of the lumen of the artery
A.k.a. peripheral arterial disease
Most common occlusive disease (about 95% of cases)
Demographics:
Most often seen in elderly patients
Etiology:
Associated with diabetes mellitus
Risk factors include smoking, hypertension, hyperlipidemia, obesity, and
diabetes
ARTERIOSCLEROSIS OBLITERANS:
Symptoms:
Treatment Goals:
Bilateral, progressive INTERMITTENT CLAUDICATION is usually present in
muscles
Primary symptom may be a sense of weakness or muscular “tiredness”, both the
pain and weakness/fatigue are relieved by rest
Pain at rest indicated more sever involvement; may be relieved by dangling limbs
(usually leg) over the edge of the bed to use gravity to encourage circulation
(dependent position)
*Differential diagnosis: this dependent position would relieve arterial pain
but would increase symptoms of a DVT (venous)
Treatment:
Preventive skin care is a primary goal in treatment; avoid minor injuries,
infections and ulceration
Exercise to increase collateral circulation and improved function
Diabetic neuropathy with diminished sensation of the toes or feet often occurs,
predisposing the patient to injury or pressure ulcers that may progress because
of poor blood flow and ongoing loss of sensation
RAYNAUD’S (DISEASE AND PHENOMENON)
Intermittent episodes of small artery or arteriole constriction of the extremities
causing temporary pallor and cyanosis of the digits (usually fingers)
These episodes occur in response to the cold temperature or strong emotion
(anxiety or excitement)
Arterial vasospasm in the skin constriction pale cold skin blood pools
in surrounding tissues bluish/purplish skin white red (as vessels relax
and blood flows in) warm red skin (may experience throbbing, swelling and
paresthesia)
Raynaud’s disease: primary, vasospastic disorder (idiopathic)
Raynaud’s phenomenon: secondary to another disease or underlying cause
RAYNAUD’S DISEASE:
80% of people with it are women aged 20-49 years old
Idiopathic; seems to be caused by hypersensitivity of digital arteries to cold,
release of serotonin, and congenital predisposition to vasospasm
Accounts for 65% of people affected by Raynaud’s
More “annoying than medically serious”
RAYNAUD’S PHENOMENON:
Predicted that 10-20% of the general population has this; usually women
between 15-40 years old
Secondary to other conditions (buerger’s, connective tissue disorders, hidden
neoplasms); has been known to be precipitated by use of pharmacological med’s
and by exposure to temperature changes (warm to cool/cold), also injuries to
hand (repetitive stress e.g. keyboarding, using crutches)
Nicotine constricts small blood vessels; smoking can trigger attacks in people
predisposed to this phenomenon
“The therapist must be aware that spasms and cramps can be caused by pathologies
and medication. In these cases, treatment modifications or referral to a physician may
be indicated. For example, calf muscle cramps may occur with arterial disorders, such
as
Acute arterial occlusion due to a thrombus or embolism;
Chronic arteriosclerotic vascular disorder due to arterial narrowing and
fibrosing, which is frequently associated with diabetes mellitus and with the aging
process;
Thromboangiitis obliterans or Buerger’s disease, an inflammatory reaction of
the arteries to nicotine, found in smokers;
And Raynaud’s syndrome, an arterial spasm due to abnormal sympathetic
nervous system firing…
intermittent claudication or pain and
cramping in the calf muscles with exercise. Intermittent claudication is due to_______.
Pain and cramping are often noted when the client is walking. They diminish slowly with
rest.
ischemia
Treatment Goals of Chronic Arterial Disease
- Improve collateral circulation and increase vasodilation
- Improve exercise tolerance for ADL’s and decrease the incidence of intermittent
claudication - Relieve pain at rest
- Prevent joint contractures and muscle atrophy
- Prevent skin ulcerations
- Improve exercise tolerance for ADL’s and decrease the incidence of intermittent
claudication through…..
regular, graded aerobic exercise program of walking, cycling, whatever they’re
able to do comfortably (consider compliance)
vasodilation by reflex heating
- Relieve pain at rest through…..
sleep with the legs in a dependent position over the edge of the bed, or with the
head of the bed slightly elevated
- Prevent joint contractures and muscle atrophy through……
active or mild resistance Range Of Motion exercises to the extremities
- Prevent skin ulcerations through….
educate guest in the proper care and protection of the skin, particularly the feet
proper shoe selection and fit
avoid use of support hose
Techniques of Examination - Peripheral arterial system
ARMS –
– inspect both arms from the fingertips to the shoulders. Note:
Size and symmetry
Color and texture of the skin and nail beds
Venous pattern
Edema
(pallor or cyanosis of the fingers indicates Raynaud’s phenomenon)
(edema and prominent veins occur with venous obstruction)
With the pads of your index and middle fingers, palpate the______ on the flexor
surface of the wrist laterally. Compare the volume of the pulses on each side.
radial pulse
Arterial occlusion in the____ is much less common than in the _____.
arms
legs
If arm pulses are
markedly diminished or absent, however, consider
thromboangiitis obliterans (Buerger’s disease), scleroderma, or, possibly, a cervical rib
If arterial insufficiency is suspected, palpate also 1) for the ______ , on the flexor
surface of the wrist medially, and 2) for the______ , in the groove between the
biceps and triceps muscle above the elbow.
ulnar pulse
brachial pulse
Since the normal ulnar artery is frequently not palpable, the Allen Test may be useful. It
tests the patency of the
ulnar and radial arteries in turn.
The Allen Test
Ask the patient to rest his/her
hands in their lap. Place your thumbs over their radial arteries and ask them to clench
fists tightly. Compress the radial arterial firmly, then ask the patient to open hands into a
relaxed position. Observe the colour of the palms. Normally they should turn pink
promptly. Repeat occluding the ulnar arteries.
Persistence of pallor when one artery (e.g. the radial) is manually compressed indicates
occlusion of the other (e.g. the ulnar).
The Allen Test – version 2
1) The hand is elevated and the person is asked to make a fist for about 30 seconds.
2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of
them.
3) Still elevated, the hand is then opened. It should appear blanched (pallor can be
observed at the finger nails).
4) Ulnar pressure is released and the color should return in 7 seconds.
Inference: Ulnar artery supply to the hand is sufficient.
If colour does not return or returns after 7–10 seconds, then the ulnar artery supply to
the hand is not sufficient.
Capillary Refill Test:
Check the finger nails for cracked nails and skin integrity first.
Then apply pressure on nail bed for 10 seconds. Release and observe the color of the
nail bed. The color should return within 7-10 seconds. If the color remains white longer
then there is arterial insufficiency
Acute arterial occlusion due to
a thrombus or embolism;
Chronic arteriosclerotic vascular disorder due to
to arterial narrowing and fibrosing, which is frequently associated with diabetes mellitus and with the aging process
Thromboangiitis obliterans or Buerger’s disease, an….
inflammatory reaction of the arteries to nicotine, found in smokers;
Raynaud’s syndrome, an
an arterial spasm due to abnormal sympathetic nervous system firing…
Edema stimulates pain receptors because of the
tension in the tissues, blocks off
circulation inflow to the tissues and impairs mobility
Edema means swelling caused by
fluid in your body’s tissues. It usually occurs in the
feet, ankles and legs, but it can involve your entire body.
Causes of edema include…..
local problems or may be a result of a systemic condition: Eating too much salt Sunburn Histamine reactions Heart failure Kidney disease Liver problems from cirrhosis Pregnancy Problems with lymph nodes, especially after mastectomy Some medicines Obstruction of lymphatic vessels Trauma Standing or walking a lot when the weather is warm
What is Lymph?
Lymph is the excess clear, watery interstitial fluid that is pumped through the arterial
ends and not absorbed by the venous vessels. This fluid is returned to the circulation
by the lymphatic system. It contains white blood cells, plasma proteins, fats and debris
such as cell fragments, bacteria and viruses.
How Does Lymph Move?
Lymphatic vessels have a minor contractile ability that is stimulated by the vessels filling
or externally by massage to the vessels. Light massage is used to not compress and
close off the vessels. Most of the lymph flow is stimulated by the surrounding skeletal
muscles, diaphragm and peristalsis and contraction of the arteries the lymphatic vessels
are in contact with. Lymph flow is unidirectional to the heart.
Edema History:
causes, general health history, cardiovascular health, kidney or liver diseases,
injuries (when was the injury, MOI, is the joint affected), infections, surgery, pregnancy
(BP, has md or midwife assessed) how long they have had it, have they seen a doctor,
are they cleared for treatment, are they on medication, underlying pathologies, ADLs,
do they use any devices to assist with swelling (stockings/bandages etc), are they
seeking other treatments?
Edema Observation:
compare bilaterally for swelling, postural observation, gait, ROM to assess
affected joints, skin quality/tissue integrity, color of tissue, area affected
Edema Palpation:
tenderness, heat, coolness, pulses (may not be able to feel due to swelling),
density/quality of edema (firm, boggy, taut)
Edema Movement:
Decreased ROM for joints affected
Edema Neurological:
nerve compression may be a factor with swelling
Edema Referred pain:
may be due to nerve compression
Edema Special tests:
girth measurement of affected area (test bilaterally if applicable), pitted
edema test.
Girth Measurement:
Use measuring tape to record measurements and compare bilaterally. Take a few
measurements as close to bony landmarks as possible to measure accurately.
Pitted Edema test:
Compress the tissue with the pad of your finger and hold for 5-10 seconds.
Release and observe the tissue for a remained compression. If the tissue remains pitted
or indented, an underlying pathology may be the cause.
Compare bilaterally.
For the lower extremity: You should do this in the anterior shin, behind the medial
mallelous and on the dorsum of the foot.
Types of Venous Disorders
- Acute Thrombophlebitis
- Chronic Venous Disorders
- chronic venous insufficiency
- varicose veins
Thrombophlebitis
e swelling of a vein due to a blood clot. Clots may be as long as 20 inches
along the wall of the vein. This is not a condition that can be treated by RMTs. The risk of
dislodging the clot poses serious complications.
Risk Factors for Deep Vein Thrombosis
Age (over 40 years old and elderly) Prolonged immobilization Cardiac failure, stroke or heart disease Anesthesia and surgery Trauma, especially in the legs or pelvis History of thromboembolism Pregnancy and post partum state Oral contraceptive pill Diabetes mellitus Lung or pancreatic cancer Clotting disorders Nursing home residents
What are signs and symptoms of DVTs?
May have localized redness and warmness to the area. A cord like swelling along the
course of the vein. Pain at rest and increased with movement.
There may also be no symptoms present.
DVT History:
Family history, have they been diagnosed, have they been cleared of a dvt,
symptoms they experience, how long have they had them, associated calf
cramping/intermittent claudication, history of recent surgery/immobilization,
pregnant/post partum, heart disease, health history (DVT risk factors), pain increase
with elevation, pain does not decrease in dependent position.
DVT Observation:
look edema, redness cord like swelling.
DVT Palpation:
pain, heat, swelling
DVT Movement:
would not do with suspected DVT.
DVT Neurological:
compression from edema possible
DVT Referred pain:
intermittent claudication
DVT Special tests:
Homan’s test (rule out dvt). Refer to MD for diagnosis if you suspect DVT
is present
Homan’s test (rule out dvt)
forced dorsiflexion of the ankle exerting traction on the posterior tibial vein, causing pain.While classically described in patients with venous thrombosis of calf veins, patients with herniated intervertebral discs and many other conditions have also been noted to exhibit a positive Homans’ sign.
(A positive sign is present when there is pain in the calf on forceful and abrupt dorsiflexion of the patient’s foot at the ankle while the knee is extended.)
Great and Small Saphenous Veins are frequent locations of ______
General
massage is ______ over varicosities.
varicosities
contraindicated
Evaluation of Venous Disorders
- Girth measurements of extremity
- Competence of the Greater Saphenous Vein
- Tests for possible Deep Venous Thrombosis
- Doppler Ultrasound: venogram; phlebogram
Define Varicose Veins
Varicose veins are swollen, twisted, and sometimes painful veins that have filled with an
abnormal collection of blood.
Causes of Varicose Veins
Prolonged sitting, standing, sitting with legs crossed, tight garter, girdle or
waist band
Obesity, heavy lifting, chronic constipation or pregnancy
Secondary to impaired or blocked blood flow from:
Deep vein thrombosis
Congenital venous malformation
Heart failure, liver dysfunction
Abdominal tumor
Vitamen C deficieny can weaken the collagen structure of the veins
Varicose Veins – Symptoms
Twisted, bulging blue lines running down all or part of a leg
Legs that ache or become tired and weak, especially after long periods of sitting
or standing
Restless legs or legs that are so uncomfortable that a person has difficulty
standing on both feet at once
Burning or itchy skin on the legs
Legs and/or ankles that become swollen and possibly have brownish
pigmentation
Leg cramps, especially in calf muscles often occur at night
Varicose Veins History:
Family history, have they been diagnosed, have they been cleared of a dvt,
have they had recent medical intervention to vv, are they painful/sensitive to touch,
symptoms they experience, how long have they had them, associated calf
cramping/intermittent claudication, history of recent surgery/immobilization,
pregnant/post partum, heart disease, health history (DVT risk factors).
Varicose Veins Observation:
look for twisting, bulging, inflammation, edema
Varicose Veins Palpation:
pain, heat, swelling
Varicose Veins Movement
would not do with suspected DVT.
Varicose Veins
Neurological:
compression from edema possible
Varicose Veins Referred pain:
intermittent claudication or nerve compression
Varicose Veins Special tests:
Homan’s test (rule out dvt) leg elevation or greater saphenous manual
compression test
Tests for Varicose Veins
Leg Elevation
Elevate legs
Observe whether “normal” bulging of vein disappears
Varicose veins will not disappear completely because the faulty vein has
stretched beyond its normal diameter and length
Tests for Varicose Veins
Greater Saphenous Manual Compression Test
Patient is standing. Place one hand at the superior portion of the greater
saphenous vein and the other hand about 20 cm below
Compress the upper portion of the vein with your fingers and palpate with the
lower fingers.
A pulse of blood in the lower hand indicates valve insufficiency
