Rehab Guidelines: arterial, venous, and lymphatic Flashcards
Arterial: What to consider for limb protection
- avoid excessive strain
- protect extremities from injury
- protect from extreme temperatres
- bed rest may be required if gangrene, ulceration, acute arterial disease are present
Arterial: specific exercises to prescribe for PAD
- consider interval training (multi-stage discontinuous protocol) with frequent rests
- waking program: intensity such that pt. reports 1 on claudication scale wi/in 3-5 min, stopping if they reach 2 (until pain subsides), total 30-60 min (intervals as necessary), 3-5 days per week
- record time of pain onset and duration
- Non-weight bearing exercise (cycle ergometry, arm ergometry) may be necessary in some pts.; less effective in producing a peripheral conditioning effect.
Arterial: Benefits of exercise for PAD
- improved functional capacity
- improved peripheral blood flow via collateral circulation
- improved muscle oxidative capacity
Arterial: shoe considerations for PAD
- well-fitting shoes are essential
- teach proper foot inspection and care to pts. w/ insensitive feet
Arterial: Medication considerations for PAD
- beta blockers for treatment of hypertension or cardiac disorders may decrease time to claudication or worsen symptoms
- pentoxifylline, dipyridamole, aspirin, and warfarin may improve time to claudication
Arterial: LE exercises (not specifically PAD)
- Modified Buerger-Allen exercises
- Resistive calf exercises: most effective mothod of increasing blood flow
What are modified Bueger-Allen exercises
- Postural exercises plus active plantar and dorsiflexion of the ankle
- Active exercises improve blood flow during and after exercise
- Effects less pronounced in patients w/ PAD
Arterial: medical treatment pts. will receive
- medications to decrease blood viscosity, prevent thrombus formation eg. heparin
- vasodilators: controversial
- calcium channel blockers in vasospastic disease
Arterial: surgical management
- atherectomy, thromboembolectomy, laser therapy
- revascularization: angioplasty or bypass grafting
- sympathectomy: results in permanent vasodilation, improvement of blood flow to skin
- amputation when gangrene is present
Venous: guidelines for DVT
- early stages may be symptomatic
- symptoms: dull ache, pain, tenderness in calf, may see slight edema or fever
- anticoagulation medications such as low molecular weight heparin’
- don’t recommend bed rest after diagnosis after the intiation of anticoagulation therapy unless significant medical concerns are present
Venous: management of edema with chronic venous insufficiency
- positioning
- compression therapy
- exercise
Venous: management of edema with chronic venous insufficiency- more info about positioning
- extremity elevation min of 18cm above heart
- encourage extremity elevation, discourage dependent position
Venous: management of edema with chronic venous insufficiency- more info about compression therapy
- bandages (elastic and tubular); applied w/in 20 min of rising
- paste bandages (unna boot) . guaze impregnated with zinc oxide, gelatin, glycerine; applied for 4-7 days (less with some wounds)
- graduated compression stockings with a pressure gradient 30-40 mm Hg
- compression pump therapy, used for 1-2 hour session twice daily
- *Red Flag: consider consequences of compression therapy to a limb with an ABI <0.8 or with evidence of active cellulitis or infection.
Venous: management of edema with chronic venous insufficiency- more info about exercise
- active ankle pumps: emphasis on muscle pumps exercises (dorsi/plantarflexion, circles)
- cycle ergometry in sitting or attached to foot of bed
- early ambulation as soon as pt. is able to get out of bed , 3-4 x a day
Venous: management of edema with chronic venous insufficiency- skin management
- pt. education for meticulous skin care
- severe conditions w/ dermal ulceration may require surgery (ligation and vein stripping, vein grafts, valvuloplasty)
Lymphatic: Phase 1 management of edema secondary to lymphatic dysfunction- the basics
- short stretch compression bandages worn 24 hours/day
- manual lymph drainage (MLD) w/ complete decongestive therapy
- functional activities
- meticulous skincare, hygiene, nail care
- compression garments at the end of phase 1
Lymphatic: Phase 1 management of edema secondary to lymphatic dysfunction- contraindicated modalities
- ice, heat, hydrotherapy, saunas, contrast baths, paraffin
- cause vasodilation and increase lymphatic load of water
- no electrotherapeutic modalities greater than 30Hz.
Lymphatic: Phase 1 management of edema secondary to lymphatic dysfunction- red flags
- excessively high pressures (think compression garments) will occlude superficial lymph capillaries and restrict fluid absorption
- strenuous activities, jogging, and ballistic movements are contraindicated. likely to exacerbate lymphedema
Lymphatic: Phase 1 management of edema secondary to lymphatic dysfunction- more on manual lymph drainage (MLD) w/ complete decongestive therapy
- massage and PROM to assist lymphatic flow
- emphasis is on decongesting proximal segments first (trunk quadrant), then extremities, directing flow distal to proximal
- compression using multilayered padding and short stretch bandages
- bandages have a low resting pressure and high working pressure
- bandages maintain limb after techniques applied to reduce limb
- decongestive exercises with padding in place. activate muscles in extremity. work trunk and limb girdle exercises first, then limb muscles from proximal to distal. performed with compression bandages on.
- done by certified lymphedema therapists
Lymphatic: signs of lymphatic overload
- discomfort
- aching
- pain in proximal lymph areas (axilla or inguinal areas)
- changes in skin color
- if any of these are present, discontinue and exercises or functional activities
Lymphatic: Phase 1 management of edema secondary to lymphatic dysfunction- more on functional activities
- walking program, cycling
- water-based programs, swimming
- tai chi and balance activities
- ADL training
Lymphatic: components of Phase 2 management (self-management)
- skin care
- compression garments
- exercise
- lymphedema bandaging at night
- MLD as needed
- compression pumps: use with caution, limited benefits
- –Red flag: pressure higher than 45 mm Hg are contraindicated, can cause lymphatic collapse, contraindicated for soft tissue injury
Lymphatic: education
- skin and nail care
- self bandaging, garment care
- infection management
maintain exercise while preventing lymph overload.
**surgery to assist lymph drainage is for severe cases only
