*PTA 200- Compression Objectives

Question 1

List the components for skilled documentation of compression therapy and document a physical therapy session for compression intervention.

Answer 1

• Patient education/instructions- explain process and why, explain HEP if going to do it at home.
• Pre/post assessments- HR and BP (and position) (BP taken on opposite limb if performing compression on UE), skin integrity and sensation.
• Circumferential measurements pre and post (if global measure entire limb, if local measure joint area). Note how often you measure (every 2-3 inches). Note landmarks.
• Cycle- 3:1 ex. 45:15 seconds
• Tx duration
• RESPONSE to pt ed and compression pump use

Question 2

Demonstrate patient education for issues related to edema control.

Answer 2

RICE, don’t stay seated for more than an hour at a time, stay active, when sitting or laying perform AP’s frequently .
To be continued…. when discussed in class

Question 3

Demonstrate patient education for care/use of external compression bandages/garments as well as foot care for diabetes and CVI.

Answer 3

Care of bandage/garment-
Use of bandage/garment-
Foot care- keep feet clean and dry, check feet daily, wear proper foot wear..
to be continued…when discussed in class

Question 4

Discuss and demonstrate wrapping an upper and lower extremity with an ACE (long stretch) Bandage to control edema

Answer 4

Start bandage at distal portion on a diagonal. Pressure should be higher distally and will decrease proximally. Overlap the wrap 1/3 of width. Work the bandage with the roll on top - “snail”. Wrap the extremity diagonally, reversing the direction with each turn using a figure eight pattern creating a criss-cross effect. Make sure heel is completely enclosed and no gaps will occur for full AROM. When finished ask patient to perform AP’s to ensure wrap will not have gaps with movement. Check toes for pink or warmness. There should not be numbness or tingling. If present, re-wrap.

Question 5

Discuss and demonstrate measurement of an extremity for a custom-made compression garment.

Answer 5

Start measurement at a bony landmark, record the distance of each measurement and record the circumference of the limb. Distance should be 2-3 inches or what PT wants. Mark skin (with permission) at each measurement.

Question 6

Discuss and demonstrate the use of an intermittent compression device to decrease edema.

Answer 6

The use of an IPC pump is to stabilize edema by facilitating venous return by intermittently compressing the extremity. Indicated for edema, DVT prevention, venous stasis ulcers and residual limb reduction. Refer to Intermittent pnuematic pump procedure worksheet for demonstration instructions.

Question 7

Indications and Contraindications for external compression (IPC pump, pre-fab/custom compression garments, short stretch bandages, Circ -Aid)

Answer 7

Indications: edema, DVT prevention, venous stasis ulcers and residual limb reduction.

Contraindications:

• An ABI of < 0.8
• kidney dysfunction (kidney may not be able to excrete the additional fluid)
• Heart failure or pulmonary edema
• Recent or acute DVT, thrombophlebitis, or pulmonary embolism
• Odstructed lymphatic return or venous return
• Severe peripheral arterial disease or ulcers resulting from arterial insuffiency
• Acute local skin infection
• Significant hypoproteinemia (protein levels <2 gm/dL)
• Acute trauma or fx
• Arterial revascularization

Question 8

Discuss the anatomy of the following as it relates to the peripheral vascular system: arterial system, venous system, and lymphatic system.

Answer 8

The peripheral vascular system = veins and arteries of the arms, hands, legs, and feet.

The circulatory system consists of 2 types of blood vessels; veins, and arteries.

Arteries; carry oxygen nutrient rich blood from the heart to organs and cells.

Veins; carry oxygen depleted blood and wastes through the kidneys, liver, and lungs. After wastes are removed, venous blood is filled with oxygen in the lungs and returned back to the heart.

Arteries and veins are interconnected by small weblike vessels called capillaries.

Lymphatic System; to prevent lymph from accumulating in the interstitial space, the lymphatic system acts as an accessory channel and returns this fluid to the blood circulation.

-the lymphatic system relies on a peristaltic motion and valvular closure to move fluid toward the central ducts that empty into the VENOUS SYSTEM.

Question 9

Define edema and discuss ways to treat edema.

Answer 9

Edema= increased fluid in the interstitial spaces.

Interventions for Edema:

• heat for chronic edema
• cold
• EMS
• elevation of body part above the heart
• massage to decrease venous and lymphatic edema
• exercise to manage/control edema
• external compression

Question 10

Discuss the pathology and signs and symptoms of Arteriosclerosis Obliterans

Answer 10

AKA: PAD, Peripheral Artery Disease, Peripheral Vascular Disease, PVD

arterial dysfunction:
“Hardening of the arteries”

Symptoms:

• intermittent claudication
• rest pain- pain during rest, sleeping, or anytime limb is in non-dependent position (anytime leg is not hanging down). Associated with 80-90% occlusion.

Question 11

Discuss the pathology and signs and symptoms of Thromboangiitis Obliterans

Answer 11

AKA: Buerger’s Disease
arterial dysfunction:
-Recurring, progressive inflammation and clotting of small and medium arteries and veins appearing in distal extremities first (hands and feet) and then progresses proximally.

• Similar to arteriosclerosis but different in that it occurs primarily in young, male smokers.
• Nicotine is a potent vasoconstrictor and in this disease this is an inflammatory process with eventual tissue necrosis.
• Condition is arrested if person stops smoking.

Symptoms:

• pain in hands and feet
• fingers and toes become pale, red, bluish or cold
• intermittent claudication

Question 12

Discuss the pathology and signs and symptoms of Raynaud’s Phenonmenom

Answer 12

arterial dysfunction:
-disease characterized by spasms of the arteries in the extremities especially in the fingers.

• vasospastic disease
• can be predicated by exposure to cold or stress
• one PT intervention = contrast baths

Symptoms:

• cold fingers and toes
• sequence of color changes in skin in response to cold or stress
• numb, prickly feeling upon warming.

Question 13

Discuss the pathology and signs and symptoms of Diabetes Mellitus

Answer 13

arterial dysfunction:
-caused by deficiency of insulin which results in failure to metabolize sugars and starch.

• accelerated atherosclerosis with angiopathy (disfunction of the vessels) and neuropathy (numbness and tingling)
• decreased sensation/poor healing
• diabetic ulcers are most commonly located on the plantar aspect of the foot

Symptoms:

• frequent urination
• excessive thirst
• unexplained weight loss
• extreme hunger
• sudden vision changes

Question 14

Discuss the pathology and signs and symptoms of Varicose Veins

Answer 14

venous dysfunction:

• swollen, twisted and painful veins that have filled with an abnormal collection of blood. (large bulbous enlargements of the veins beneath the skin). Usually attributed to incompetent valves.
• Linked to family history

Symptoms:

• veins that are dark purple or blue
• veins that appear twisted or bulging

Question 15

Discuss the pathology and signs and symptoms of Chronic Venous Insufficiency

Answer 15

venous dysfunction:

AKA CVI

• Characterized by micro and macro circulatory dysfunction of the venous system causing distention (the state of being stretched beyond normal dimensions)
• Valves fail and do not close properly leading to venous reflux. (backward flow of blood through a distended vein.)
• Veins can’t pump enough oxygen poor blood back to the heart.

Symptoms:

• extreme edema in lower legs
• new varicose veins
• aching or tiredness in legs
• dermatitis
• stasis pigmentation (hemosiderin)

Question 16

Discuss the pathology and signs and symptoms of Primary Lymphedema

Answer 16

lymphatic dysfunction:

Primary Lymphedema- occurs on its own. A condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system.

-Can affect from one to as many as four limbs and/or other parts of the body, can be present at birth, develop at the onset of puberty (praecox) or in adulthood (tarda), all from unknown causes, or associated with vascular anomolies such as hemangioma, lymphangioma, Port Wine Stain, Klippel Trenaury.

Question 17

Discuss the pathology and signs and symptoms of Secondary Lymphedema

Answer 17

lymphatic dysfunction:

Secondary Lymphedema- caused by another disease or condition.

• acquired lymphedema, can develop as a result of surgery, radiation, infection or trauma. Specific surgeries, such as surgery for melanoma or breast, gynecological, head and neck, prostate or testicular, bladder or colon cancer, all of which currently require removal of lymph nodes, put patients at risk of developing secondary lymphedema. If lymph nodes are removed, there is always a risk of developing lymphedema.
• can develop immediately post-operatively, or weeks, months, even years later.

Question 18

Define Acrocyanosis

Answer 18

persistent blue discoloration of the extremities. Most commonly the hands but can occur in the feet.

Question 19

Define Erythromelalgia

Answer 19

bilateral vasodilatation affecting the extremities by redness, burning, and throbbing sensations and increased skin temperatures.

-condition characterized by episodes of pain, redness, and swelling in various parts of body particularly the feet and hands.

Question 20

Define Cyanosis

Answer 20

Appearance of blue or purple discoloration of the skin due to tissues being low on oxygen.

Question 21

Define Trophic Changes

Answer 21

changes resulting from interruption of nerve supply.

Question 22

Define intermittent claudication

Answer 22

the supply of blood is less than the muscle demand which produces pain and cramping in the involved muscles. (usually the calf muscles).

-Intermittent Claudication is associated with 50% occlusion of the affected vessel.

Question 23

Define Hemosiderin Staining

Answer 23

development of patches of brownish to yellow deposits just under the skin. It usually occurs as a byproduct of the breakdown of red blood cells, and patients can develop such deposits in the wake of surgery or hemorrhage. These patches also occur as a result of heart failure, vascular insufficiency, and other cardiovascular diseases.

Question 24

Discuss the PT’s exam/eval of a patient with suspected PVD (peripheral vascular disease)

Answer 24

Exam/Eval Includes:
1.history-

2.systems review-may indicate referral to other practitioners.

3. tests and measures:
   a. )aerobic capacity/endurance
   b. )anthropometric measurement; which includes height and weight, volumetric measurement, and girth measurement.
   c. )palpation and pitting
   d. )arousal and attention
4. circulation;
   a. )temperature and arterial perfusion (checking for circulation through arteries),
   b. )grading of the pulse,
   c. )dorsalis pedis and posterior tibial arterial perfusion.
   d. )ABI assessment-measure of arterial perfusion.
   e. )arterial trophic changes; skin color, loss of hair growth on lower leg, dry and thickened nails.
   f. )pain, arterial vs venous issues, intermittent claudication
   g. )special tests- includes tests for DVT, Stemmer’s Sign, Rubor of Dependency
5. ) Gait, Locomotion, and Balance
6. ) Integumentary Integrity- includes observation and palpation, trophic changes, fibrosis, coloration, wounds.

Question 25

Discuss the PT’s exam/eval of a patient with suspected PVD (peripheral vascular disease

Answer 25

Exam/Eval Includes:
1.)History- many causative factors have slow insidious onset, so obtaining history may be challenging.

2.)Systems Review-may indicate referral to other practitioners.

3. )Tests and Measures:
   a. )aerobic capacity/endurance
   b. )anthropometric measurement; which includes height and weight, volumetric measurement, and girth measurement.
   c. )palpation and pitting
   d. )arousal and attention
4. )Circulation:
   a. )temperature and arterial perfusion (checking for circulation through arteries),
   b. )grading of the pulse,
   c. )dorsalis pedis and posterior tibial arterial perfusion.
   d. )ABI assessment
   e. )arterial trophic changes; skin color, loss of hair growth on lower leg, dry and thickened nails.
   f. )pain, arterial vs venous issues, intermittent claudication
   g. )special tests- includes tests for DVT, Stemmer’s Sign, Rubor of Dependency
5. ) Gait, Locomotion, and Balance
6. ) Integumentary Integrity- includes observation and palpation, trophic changes, fibrosis, coloration, wounds.

Question 26

Discuss physical therapy intervention for Lymphadema: basic exercise, basic wound management, Unna Boot, edema control measures, and pt ed.

Answer 26

External compression. NOT IPC pump.
Exercise- staying active
Basic wound management- Unna boot
Manual lymphatic drainage
to be continued...

Question 27

Discuss tests and/or testing devices used in evaluation of PVD: Homan’s Test

Answer 27

Test for DVT.
Squeeze the gastroc while forcefully DF the ankle. + Acute pain = Homan’s sign. Doppler Ultrasound will be performed on all patients with Lymphedema to R/O DVT.
NO LONGER CONSIDERED VALID- A DOPPLER US should access for DVT.

Question 29

Discuss tests and/or testing devices used in evaluation of PVD: Thermometer

Answer 29

Temperature can be examined by palpation. A decrease in temperature can indicate poor arterial perfusion and circulation. An increase can indicate edema, infection, venous problems or active disease processes.

Question 30

Discuss tests and/or testing devices used in evaluation of PVD: Circumferential and volumetric measurement

Answer 30

Athropometric measurements–
Circumferential (or AKA Girth): recorded using a measuring tape. Use consistent centimeter intervals or bony landmarks. The smaller the interval the better the representation of body dimensions.
Volumetric: performed utilizing special containers that hold hot water, and a graduated cylinder for water collection. (figure 17.10 pg. 658) This method is accurate for measuring changes in body dimensions; however it is time consuming , awkward and may be inappropriate for open wounds owing to cross-contamination risks.

Question 31

Discuss tests and/or testing devices used in evaluation of PVD: Ankle-Brachial Index

Answer 31

Assessment of arterial perfusion. Can indicate loss of perfusion in the LE.
Sometimes referred to as ABPI Ankle-Brachial Pressure Index (LE systolic pressure/UE systolic pressure)
Normal values are .95 to 1.19, ABI’s greater than 1.2 are falsely elevated, indicate arterial disease or diabetes.
ABI’s of greater than 0.8 compression of 30-40 mm Hg can be used. Do not use compression with ABI’s less than 0.8 because they have an arterial insufficiency and they’re having trouble getting blood to the area and you don’t want to use compression on someone who has an arterial insufficiency.
-120 mmhg LE/ 140mmhg UE = .86 ABI
-Only tested for LE perfusion
-Tests to determine adequate blood flow is reaching distal tissues.

Question 32

Discuss tests and/or testing devices used in evaluation of PVD: Rubor of Dependency

Answer 32

the pt is positioned supine and the affected LE elevated to 45% x several seconds. Arterial disease causes limb to require 20-30 seconds to return to normal coloration. If color returns immediately venous insufficiency may be indicated.

Question 33

Discuss physical therapy intervention for Chronic Arterial Disease: basic exercise, basic wound management, edema control measures, and pt ed.

Answer 33

• Goals are to improve circulation and educate
• Exercise Helps to improve circulation- walking program/increase amount of time walked before intermittent claudication becomes a problem. There are formalized walking programs that we will not cover because these programs are beyond the scope of this lecture.
• Wound management - moist occlusive dressing, foot care. No absorptive dressings. NO COMPRESSION (because the blood flow is having trouble even getting to the area in the first place and compressing it would make it worse). Avoid debridement. -Use US technique on intact black heels, EMS for wound care.

Question 34

Discuss physical therapy intervention for Chronic Venous Disease: basic exercise, basic wound management, edema control measures, and pt ed.

Answer 34

• Goals are to decrease edema, prevent and/or heal ulcerations and educate on skin and foot care.
• Treat edema with intermittent pneumatic compression pump (IPC) and custom fitted stockings
• Use compression pump 1st for several treatments until edema stabilized then measure for a custom-fit stocking.
• Use wraps (short-stretch or ace), tubigrip, etc before custom garments arrive.
• Exercise very important and tell patient to elevate legs post treatment, until HR returns to normal. “don’t sit more than 1 hour without walking”.
• Wound Care – occlusive/absorptive dressings with IPCP/compression garments for CVI. Unna Boot that is used only for ambulatory patients.

Question 35

Discuss tests and/or testing devices used in evaluation of PVD: Doppler Ultrasound

Answer 35

uses reflected sound waves to see how blood flows through a blood vessel. It helps doctors evaluate blood flow through major arteries and veins, such as those of the arms, legs, and neck.