Rehab Guidelines: arterial, venous, and lymphatic

Question 1

Arterial: What to consider for limb protection

Answer 1

• avoid excessive strain
• protect extremities from injury
• protect from extreme temperatres
• bed rest may be required if gangrene, ulceration, acute arterial disease are present

Question 2

Arterial: specific exercises to prescribe for PAD

Answer 2

• 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.

Question 3

Arterial: Benefits of exercise for PAD

Answer 3

• improved functional capacity
• improved peripheral blood flow via collateral circulation
• improved muscle oxidative capacity

Question 4

Arterial: shoe considerations for PAD

Answer 4

• well-fitting shoes are essential

- teach proper foot inspection and care to pts. w/ insensitive feet

Question 5

Arterial: Medication considerations for PAD

Answer 5

• 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

Question 6

Arterial: LE exercises (not specifically PAD)

Answer 6

• Modified Buerger-Allen exercises

- Resistive calf exercises: most effective mothod of increasing blood flow

Question 7

What are modified Bueger-Allen exercises

Answer 7

• 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

Question 8

Arterial: medical treatment pts. will receive

Answer 8

• medications to decrease blood viscosity, prevent thrombus formation eg. heparin
• vasodilators: controversial
• calcium channel blockers in vasospastic disease

Question 9

Arterial: surgical management

Answer 9

• 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

Question 10

Venous: guidelines for DVT

Answer 10

• 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

Question 11

Venous: management of edema with chronic venous insufficiency

Answer 11

• positioning
• compression therapy
• exercise

Question 12

Venous: management of edema with chronic venous insufficiency- more info about positioning

Answer 12

• extremity elevation min of 18cm above heart

- encourage extremity elevation, discourage dependent position

Question 13

Venous: management of edema with chronic venous insufficiency- more info about compression therapy

Answer 13

• 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.

Question 14

Venous: management of edema with chronic venous insufficiency- more info about exercise

Answer 14

• 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

Question 15

Venous: management of edema with chronic venous insufficiency- skin management

Answer 15

• pt. education for meticulous skin care

- severe conditions w/ dermal ulceration may require surgery (ligation and vein stripping, vein grafts, valvuloplasty)

Question 16

Lymphatic: Phase 1 management of edema secondary to lymphatic dysfunction- the basics

Answer 16

• 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

Question 17

Lymphatic: Phase 1 management of edema secondary to lymphatic dysfunction- contraindicated modalities

Answer 17

• ice, heat, hydrotherapy, saunas, contrast baths, paraffin
• cause vasodilation and increase lymphatic load of water
• no electrotherapeutic modalities greater than 30Hz.

Question 18

Lymphatic: Phase 1 management of edema secondary to lymphatic dysfunction- red flags

Answer 18

• 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

Question 19

Lymphatic: Phase 1 management of edema secondary to lymphatic dysfunction- more on manual lymph drainage (MLD) w/ complete decongestive therapy

Answer 19

• 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

Question 20

Lymphatic: signs of lymphatic overload

Answer 20

• 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

Question 21

Lymphatic: Phase 1 management of edema secondary to lymphatic dysfunction- more on functional activities

Answer 21

• walking program, cycling
• water-based programs, swimming
• tai chi and balance activities
• ADL training

Question 22

Lymphatic: components of Phase 2 management (self-management)

Answer 22

• 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

Question 23

Lymphatic: education

Answer 23

• 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