Assessment of peripheral Vascular System

It is important to distinguish between an impaired arterial supplies, reduced venous

drainage and impaired lymphatic drainage, though of course more than one
impairment may coexist.

A. Examination of the arterial system:

The initial patient evaluation, regardless of the chief complaint, should include
the entire arterial system in order to identify signs of significant atherosclerosis
disease which sometimes is asymptomatic and may have been previously
unrecognized. This comprehensive examination usually provides a reasonably
accurate impression of the patients cardiovascular condition. Such evaluation
should include the following:

I- General Examination
II- Head & Neck
III- Upper Extremity
IV- Abdomen
V- Lower Extremity

I- General Examination:
a- Checking heart rate and rhythm
b- Checking of bilateral arm blood pressure
c- Neck auscultation for carotid bruits
d- Cardiac auscultation for arrhythmias and heart sounds
e- Abdominal auscultation for bruits
f- Abdominal palpation for an aortic aneurysm
g- Palpation for peripheral pulses
h- Auscultation of the femoral region for bruits
i- Inspection of the legs and feet for gangrene and microembolic phenomena

II- Head & Neck:

(Carotid bruits & enlarged carotid pulsation)
a- Inspection
- Patient is lying supine
- The head of the patient should be slightly elevated on a pillow and turned
away slightly from the carotid artery being evaluated

1
- The examiner places the diaphragm of the stethoscope over the carotid
artery and ask the patient to hold his breath during auscultation

Normally: Either nothing or transmitted heart sound will be heard.

Abnormally: Presence of a murmur, this may be a bruit resulting from
atherosclerosis of the carotid artery.

What is bruit? It is abnormal sounds occurred in arteries due to

turbulence in arteries caused by an increase velocity or obstruction.

(Enlarged carotid
pulsation)
Normally: The
carotid pulsation is not
visible
Abnormally: The carotid pulsation may become prominent at the base of
the neck in patients with long standing hypertension or carotid artery
aneurysm

b- Palpation:
The common carotid pulse is palpable low in the neck between the mid
line of trachea and the anterior border of sternocleidomastoid muscle.

2
III- Upper extremity:
The most common symptoms suggesting upper extremity arterial
insufficiency are Pain, Coldness and Exertional muscle fatigue (arm
claudication)
a- Inspection:
Color of fingertips and the hands (Filling time).
Normally: Pink fingertips with a capillary refill time of less than 3
seconds are a reliable sign of adequate perfusion of the arm and hand.
Abnormally: Pale, white coloration, diminished or absence of motor
function and painful hand.
b- Palpation:
The upper extremity arterial pulsation can be palpated at three locations:
1- The upper medial arm just distal to the axilla and in the groove between
the biceps and triceps muscle (Axillary art.).
2- The antecubital fossa just medial to the biceps tendon (Brachial art.).
3- At the wrist over the distal radius (Radial art.).

Palpate the radial pulse: The symmetry of the pulses is evaluated for
timing and strength in the same time.

Normally: There is no difference in strength and rhythm.

Abnormally: Strong pulse in case of atherosclerosis.
Weak or absence of pulse in vasospastic disease. When pulses are not
palpable, Doppler can be used to assess arterial signals and measure arm
and forearm blood pressure.
In arm claudication: the arm should be exercised for 2-5 minutes and the
brachial pressure rechecked. Brachial pressure should be fall if there is
severe arterial occlusion.

Palpate the brachial pulse: Because the brachial pulse is stronger than
digital pulses, the examiner may use his thumb to palpate the brachial
pulse. Once the examiner feels the brachial pulsation with his thumb, he
should apply progressive pressure to it until the maximum systolic force is
felt. The examiner should now be able to assess the wave form.

3
 Skin temperature: The
examiner uses the back of
his hand. The level of the
skin temperature demarcation in the acutely ischemic arm usually is just
distal to the level of occlusion.

For example: If the extremity is cold to the mid forearm the occlusion is
most likely in the brachial artery at the elbow.

c- Auscultation: Auscultation of the upper arm extremity arteries should

include measurement of bilateral brachial blood pressure.
Normally: There is a difference about10 mmHG between both arms.
Abnormally: a difference of more than 10 mmHG between arms indicates
hemodynamically significant innomirate, subclavian. Axillary, or
proximal brachial stenosis on the side with lower blood pressure.

IV- Abdomen:
a- Inspection:
The abdominal aorta
Normally: The normal abdominal aortic pulsation usually is not visible.
Abnormally: A large abdominal aortic aneurysm may be seen pulsating
against the anterior abdominal wall especially in thin patients.
b- Palpation:

4
 Palpate abdominal aorta: Having the patient relax in supine position, bend
his knees, rest his feet on the examining table and consequently flex the
hips and relax the anterior abdominal musculature.
Normally: The aorta bifurcate at the level of the umbilicus. Palpate deeply
in the mid-abdomen. Unless the patient is excessively obese the aortic
pulse is palpable.
Abnormally: The presence of mass with laterally expansible pulsation
suggest an abdominal aortic aneurysm. An aortic aneurysm should be
suspected when aortic pulse feels expansible and larger than 4-5 cm.

c- Auscultation:
Auscultation with stethoscope commonly reveals bruits when significant
occlusive disease of the aorta or its branches is present.

Abdominal bruits: The patient should be lying supine. The examiner

should place the diaphragm of the stethoscope in the midline of the
abdomen about 5cm above the umbilicus and listen carefully for the
presence of aortic bruit.
Normally: Either nothing or transmitted heart sounds will be heared.
Abnormally: The presence of murmur is to be noted in this area
suggesting abdominal bruit.

V- Lower extremity:
Physical examination is especially helpful in the initial evaluation of
arterial problems of the lower extremity. Chronic and acute arterial
insufficiency produces changes that can be recognized by inspection,
palpation, auscultation and other special techniques.

a- Inspection:
Skin changes:
Chalky white skin: arterial flow is absent or decreased.
Pale and cool: chronic arterial insufficiency.
Pigmentation: previous stasis problems.

5
 Black gangrene: acute arterial occlusion (24 hours of acute ischemia).
Muscle weakness or paralysis especially of the foot dorsiflexors: After 24
hours of acute ischemia.
b- Palpation:
1- Femoral pulse:
Patient lying on his back and the examiner at the patient Rt. side.
The lateral corners of the pubic hair triangle are observed and palpated.
The femoral artery should run obliquely through the corners of the pubic
hair triangle below the inguinal ligament and midway between the
symphysis pubic and the anterior superior iliac spine.
Both femoral pulses should be compared simultaneously.
If one of the femoral pulses is diminished or absent auscultation for bruit
is necessary.
The presence of bruit indicate aorto-ilio-femoral disease.

Rule out coarctation of the

aorta:
The timing of femoral and radial
pulses is important. Normally
theses pulses peak either at the
same time or with the femoral preceding the radial. By placing the hand
on the femoral artery and the other hand on the radial artery, the examiner
can determine the peak of these pulses. This technique performed only on
one side. Any delay in the femoral pulse is suspicious for coarctation of
the aorta especially in hypertensive individuals.

2- Popliteal pulse:

6
 The popliteal pulse is more difficult to
palpate because it lies deep in the
popliteal area.
The patient supine and the knee slightly
flexed.
The examiner should hook the fingertips
of both hands around medial and lateral
knee tendons and press the fingertips into
the Popliteal space.
The Popliteal pulse usually lies slightly lateral of midline.

3- Dorsalis pedis pulse:

The dorsalis pedis is best felt by dorsiflexion of the foot. The dorsalis
pedis artery passes along a line from extensor tendon of the great toe. The
dorsalis pedis pulses may be felt simultaneously.

Normally: This pulse is found in the mid-dorsum of the foot, between the
first and second metatarsals.
The dorsalis pedis is terminal
branche of the anterior tibial
artery.

7
 4- Posterior tibial pulse:

The posterior tibial pulse can be felt as it wraps around the medial
malleolus during planter flexion. Both arteries may be evaluated
simultaneously.
The most sensitive sign of occlusive peripheral arterial disease in patients
over 60years is the absence of posterior tibial pulse.
Normally: Pulses are palpable.
Abnormally: There partial loss of one or more peripheral pulses
depending on the severity of the condition, also the site of the occlusion.
c- Auscultation:
Auscultation of the lower extremity arteries is most useful in the femoral
area , where bruits indicate local femoral artery disease or more proximal
aorto-iliac disease with bruit transmitted to the groin.

2- Skin temperature:
Palpation is also helpful in the assessment of acute ischemic leg.
Extremity skin coldness and the level of temperature demarcation can be
detected by palpation of ischemic limb with the back of the examiner
hand, which are most sensitive to temperature.
Acute ischemia also may be associated with tenderness and tenses of
ischemic calf muscle, especially the anterior compartment.
In addition acute arterial insufficiency may cause sensory nerve damage
detected by simple pinprick sensory examination.

Other special techniques

1- Temperature gradient test:
Aim: To detect adequate blood supply to the lower limb.

8
 Procedure:- Patient in lying position.
-The back of the practitioner hand should be used to stroke
the anterior surface of the patient lower limb begining from the knee to
the toes.
Interpretation:
- Normally: The proximal part of the leg should feel worm to touch, with
gradual cooling as the feet are approached.
- Abnormally: A sharp temperature drop on a comfortably warm day will
suggest an inadequate blood supply, with possibly an obstruction
occurring at the level of sudden change.

2- Capillary filling test:

Aim: To detect the peripheral blood flow and the color of the upper and
lower extremity.
Procedure: - Patient in supine lying.
- The examiner using his thumb and should apply sufficient
pressure to the apices of the patient toes to blanch the skin.

Interpretation:
- Normally: As the practitioner remove the pressure, counting in seconds
should begin and the time taken for the normal color to be restored should
be noted. Normal color should return within 2-3 seconds on warm day and
within 5 seconds on cold day.
- Abnormally: A delay capillary filling time suggest an inadequate supply
through the capillaries producing a compromised microcirculation.
- Absence of blanching in a cyanotic foot is a bad sign, since it shows
that the tissues are devitalized and gangrenous state is likely to develop.

3- Rubor of Dependency (Burgers test) :

9
 Aim: This test is to assess the adequacy of arterial circulation by
determining skin color changes that occur with elevation and dependency
of the extremity.
Procedure: - placing the patient supine and noting the color of the soles
of the feet (Normally they will be pinkish in appearance).
-The leg should be elevated and supported, to about 450 and the patient
is asked to move his ankle in order to help drain the blood from the
venous system, making the color changes more obvious.
- The foot is inspected for pallor, after 30seconds. Mild pallor is
normal.
- At this point the patient is asked to sit dangling his feet at the side of
the bed.
- The examiner quickly assess the time for color return.
Interpretation:
- Normally: (in elevation)
-A mild pallor should then be seen within one minute in elevated position.
-A severe wide spread pallor during elevation suggest arterial
insufficiency. (This is an abnormal sign)

- Normally: (in dependency)

- The time taken for the planter surface to return to the pinkish colour is
10 seconds and 15 seconds for the superficial veins to fill.

- Abnormally:

- A delayed time of 20 seconds or more suggest that blood supply is in

adequate.

- With Severe ischemia the delay is 40 seconds or more.

- If the color on dependency is dusky red, this is a serious sign indicating

that the blood supply is severely compromised.

N.B. Burgers test has been shown to be a useful adjunct to routine

vascular assessment, and can be an indicator of more severe ischemia with
distal limb artery involvement.

4- Allens test:
10
 Aim: This test is used to determine whether arterial insufficiency exists in
the upper and lower extremities.

Procedure:
A- (For the hands)

For the patency of the radial and ulnar arteries, the radial artery is first
occluded by the examiner thumb applying firm pressure over it.

The patient is then asked to clinch his fist tightly.

The patient is asked to open his fist and the colour of the palm is
observed.

The test is repeated with occlusion of the ulnar artery.

Normally: the colour of the hand must return when the patient open his
fist

Abnormally: Pallor of the palm during compression of one artery

indicates occlusion of the other.

B- (For the feet)

This test can be used to detect occlusion distal to the ankle.
One leg of the patient is elevated and the dorsalis pedis artery is
compressed with the practitioner thumb.
Maintaining the pressure on the artery.
The leg is lowered into dependency.

Interpretation:

Normally:

If the tebialis posterior artery is patent the foot should return normally
to its normal colour.

The patency of the dorsalis pedis can be tested in similar manner by

compressing the tibialis posterior artery.

Abnormally:

11
 Delaying of recoloration of the foot or diminished colour indicates
partial or complete occlusion

5- Immersion test:
Aim:
This test is used to determine skin temperature and coloration of the
hand in Raynauds Phenomenon.
Procedure:
The patient immerses his hands in ice water for 30 seconds, then
elevate his hands out of the water.
Interpretation:
Normally:
The pre-immersion skin temperature of the digits recover in 5 10
minutes.
Abnormally:
With Raynauds Phenomenon The pre-immersion digital skin
temperature requires 15 30 minutes to recover.

B. Examination of the Venous system:

Venous disease usually localized to one anatomical area, unlike

atherosclerotic arterial disease which often involves several body regions.

The lower extremities most commonly are involved, although significant venous
problems occasionally impair function of the upper extremity.

Lower Extremities Evaluation:

The most common venous problems of the legs are varicose veins,
deep venous thrombosis and post phlebitic syndrome. Although this conditions
may be asymptomatic, they generally are associated with some degrees of leg pain
and swelling. Physical Examination is the primary method of evaluating varicose
veins and post-phlebitic syndrome. Since these conditions cause visible changes on

12
the surface of the leg. In contrast, the patient history and physical examination
often are unreliable in making accurate diagnosis of the deep venous thrombosis.

Such evaluation should include the following:

I- Inspection
Inspection should be done with both legs completely exposed from the groin to
the feet.
Important findings may be recognized by comparison of the normal and
abnormal extremities.
The patient should stand so that superficial veins fill.
It is preferable that the patient stand on a short stool while the examiner sits on
a chair or a stool.
The examiner position provides a better view of the legs.
Good overhead lighting or sunlight or adjusted bed-side examining lamp are
useful.
The entire leg should be examined as the patient turns 360o

Colour:
Telngiectasis (dilatation of the capillaries) around the medial malleolus can
indicate poor drainage.
A mottled cyanosis may often appear in the lower third of the lower limb due
to stagnation of blood in the veins as a result of poor drainage.
Atrophie blanche (white patches on the skin around the ankle) occur due to
strangled microcirculation and leads to fibrotic and sclerotic changes in the
skin.
Haemosiderosis (iron deposition in the skin) is occurred as a result of the back-
pressure in the veins giving the brown skin coloration at the lower third of the
leg.

Temprature:
The skin often feels warm, however it should be borne in mind that recent
thrombosis may result in inflammation in the veins (phlebitis) due to the
presence of the thrombosis.

Tissue Vitality:

13
Poor drainage results in accumulation of waste products. As a result, tissue
viability is adversely affected. The skin may eventually become indurated.
Atrophy, venous eczema, and venous ulcers may result.

Gravitational Eczema:
Signs of discoloration and pigmentation, scaly and lichenified skin, in the
presence of edema, haemosiderosis and Atrophe Blanche suggest a diagnosis of
gravitational eczema.
- The area can be very itchy.
- Scratching may lead to the development of ulcers.
- Patients with gravitational eczema often find that they become
sensitized to topical antibiotics and to preservative in other topical
medicaments and bandages.

Venous Ulcers:

- Commonly found around the malleoli, particular the medial one.

- Associated with gravitational eczema.
- Shallow with irregular borders, and have either a healthy or
slightly sloughy base, unless infected.
- They become painful if infected.
- Pain can be alleviated by leg elevation.
- Neglection of treatment may lead to malignancy or squamous cell
carcinoma.

Edema:

The edema due to deep venous thrombosis usually demonstrates pitting,

edema may result in ischemia around the ankle, in severe cases leading to
moist gangrene.

Leg shape:

Patients with chronic venous ulceration and edema may develop

characteristic champagne legs, also known as inverted legs.

14
 II- Palpation:

Palpation provides useful information in the evaluation of varicose veins and

acute venous thrombosis.

Palpation may help to determine the possible cause of leg swelling associated
with chronic venous insufficiency. Occasionally, chronic venous obstruction is
secondary to extrinsic compression be a pelvic, femoral, or popliteal mass, and
so, these regions should be palpated for local aneurysms or tumors.

Deep venous thrombosis may cause tenderness of calf or thigh muscles.

Note:

Such tenderness is not specific for thrombophlebitis, since muscle strain,

contusion, or hematoma may cause similar tenderness.

III- Ausculatiotion:
With a stethoscope does not provide much information about superficial or
deep venous flow. However, the Doppler unit is especially helpful in the
examination of lower extremity veins. It allows assessment of both deep vein
patency and incompetency of valves.

Tests of Peripheral Venous Circulation:

1) Varicosities:

a- Percussion Test:

Aim:
This test is designed to assess the competence of the greater saphenous
vein.

15
 Procedures:
- Having the patient stand so that the varicosities present will fill
with blood
- A segment of the vein below the knee is palpated, while the vein
fluid
above the knee is percussed simultaneously.
- Detect the fluid wave under the palpating finger.

Interpretation:
- Normally:
- If the valves were competent, the fluid wave would have been damped.

-Abnormally:
- Detecting a fluid wave under the palpating finger indicates that
the valves are incompetent and that an essent i al l y
continuous column of blood is present.

b- Trendelenburgs test:
Aim:
This test is used to determine valves incompetent of great suphenous,
deep and communicating veins.

Procedure:
- The patient lies supine and the leg is elevated 900 for 15 seconds to
empty all varicosities.
- A soft rubber tourniquet is applied to the le just below the knee ,
than the patient stands.

Interpretation:
- Normally:
- The saphenous vein should fill slowly from below
in about 30seconds, with the tourniquet in place.
- Abnormally:

.
- Filling from above indicates retrograde flow. After 30 seconds, the tourniquet
is released, any sudden filling indicates incompetent of great suphenous vein
valves.

16
 - Immediate filling of the varicosities despite a tourniquet above them
indicates incompetent deep and communicating veins.

2) Deep vein thrombosis:

a- Homans test:
Aim:
This test is used to check deep vein thrombophlebitis.

Procedure:
Patient is in supine lying position.
The examiner should squeeze the gastrocnamious while forcefully
dorsiflexing the patient ankle.

Interpretation:
Normally: There is no pain during the test
Abnormally: In acute thrombophlebitis , there is great pain in calf
muscle. This reported as positive Homans sign.

b- Pressure cuff test:

Procedure:
Patient is in supine lying position.
The examiner applies blood pressure cuff around the calf muscle and to
record how high the cuff can be inflated.

Interpretation:
Normally:
- Person can tolerate up to 120mmHG and 50mmHG more without
feeling pain or tenderness.
Abnormally:
- In case of deep vein thrombosis cannot tolerate pressure greater
than 40mmHG.

17
 Peripheral Vascular Diseases

A) DISEASES OF THE ARTERIES:

I) ATHEROSCLEROSIS:
Atherosclerosis is a diseased of the large and medium size arteries that begins
as fibro fatty deposition on the intimal surface of the vessels. It usually
causes no symptoms until the impede arterial blood flow cause ischemia or
infarction of the affected organ.

- Factors implicated for atherosclerosis

1) Age: Increased frequency with advancing age.

18
2) Diet: A diet rich in animal fat raises the serum cholesterol level and leads to
ischemic heart disease.
3) Hereditary: Increase frequency at early age within certain families.
4) Hyperlipidemia: A high level of lipids in blood stream.
5) Diabetes mellitus: Almost twofold increase as compared to nondiabetic.
6) Cigarette smoking: When nicotine is absorbed into the blood stream it
causes vasoconstriction of the small vessels.
7) Hypertension: This may accelerate vascular disease. Diastolic pressure the
most important figure.
8) Other factors: obesity, lack of exercise, occupation and life style.

- Clinical feature
These depend on the site of the affected artery.
1) Coronary arteries: Angina pectoris, conduction disturbances, myocardial
infarction
2) Carotid or vertebral arteries: Transient ischemic attack, cerebrovascular
accident or stroke.
3) Renal artery: Hypertension, renal ischemia.
4) Iliac, femoral and popliteal arteries: Intermittent claudication, rest pain,
cold limbs, skin changes, loss of pulse, edema, sexual dysfunction and other
changes.

Intermittent claudication:
Intermittent claudication is an aching, persistent, cramp like, squeezing pain
that occur after certain amount of exercise particularly walking and often
begin at the arch of the foot or calf of the leg. It is relived by rest without
change of position.
With progression of the disease pain is provoked by less exercise and takes
longer to subside, due to inadequate circulation to meet the demand of the
working muscles.

Rest pain:
Rest pain is caused by severe ischemia of tissues and terminal nerve endings.
It is described as severe ache or burning pain often occurring at night and
persisting for hours at a time. It is aggravated by elevation of the limb and
often relived by dependency.

Cold limb:
19
 The toes and feet feel cold to touch, may be associated with blanching or
cyanosis. This may vary with the level of activity and complaints of ischemic
leg pain.

Sensory changes:
Pins and needles, tingling or complete anesthesia may be present in the hands
or feet and is increased by exercise.

Skin changes:
Affected extremity may be of normal color. In advanced disease cyanosis or
an abnormal red color called rubor may be seen, particularly when the limb
is placed in dependent position.
Rubor is caused by maximal dilatation of the arterioles and capillaries of the
affected part.
The skin may be white, shiny appearance or discolored with a delay in the
return of the color after blanching. Also it may be dry, loss of hair and nails
are brittle.

Loss of pulses:
Pulsation in posterior tibia and dorsalis pedis is impaired or absent in lower
limb occlusion. Impairment of pulse in popliteal and femoral arteries is less
frequent. Pulsation may be improved on rest, which indicates that some of the
altered blood flow may be due to spasm of the artery.

Edema:
It occurs when there is severe occlusion. It is most evident when the legs are
in dependent position. Edema is not as dominant as that seen in venous
occlusion.

Treatment:
1) Medical:
a) Advices is given to:
1- Stop smoking
2- Avoid cold
3- Wear warm loose clothes
4- Keep the skin clean and free from infection or pressure
5- Avoid using hot water bottles

20
6- Avoid sitting with crossed legs
7- Avoid wearing tight shoes
8- Trauma of all kinds of the legs must be avoided
9- Use padding to keep heel off bed
b) Analgesics are prescribed to relive pain
c) Anticoagulants may be given to patients with diffuse occlusive edema
d) Diet should be low in animal fat and cholesterol
e) Reducing weight in obesity

2) Physiotherapy:
a) Foot cares
- Heel should be protected from pressure sores
- Daily foot care:
Washing feet with warm water and mild soap and not soaked in hot water to
avoid burns in sensory neuropathy.
Inspection of the foot for cuts, blisters, in growing toenails, discolored skin,
and cracks particularly the heel and spaces between the toes.
Moisturizing the skin with lanoline and Vaseline intensive care lotion
An antifungal powder should be applied between toes.
b) Position:
Head of the bed is elevated 6 inches to improve arterial perfusion of the pedal
circulation by gravity
Sheets are draped over a foot board to alleviate pressure on the foot
c) Exercises:
Exercise must be very carefully choose, and nothing be attempted to raise
blood pressure
Exercise on daily basis to the limit imposed by circulation may result in
walking distance. If there are no contraindication, it is advisable to ask the
patient with intermittent claudication to walk up to their limit twice or three
times daily
Buergers exercises may be indicated. This is a development of the collateral
circulation in the legs. The procedure is as follows:
1) The patient lies supine with legs supported in elevation (450 to horizontal)
until the skin blanches in about 2 minutes
2) The patient sits up with the legs dependent until the skin color is bright red in
about 3 minutes

21
3) The patient lies with the legs horizontal until the skin color return to normal
in about 5 minutes
This pattern of position is repeated 4 to 5 times for 3 times daily.
Improvement is determined by the decreasing time required for the changes
in skin color.
Stationary bicycle is fine but just as effective is graded walking both on the
level and on an incline.

d) Whirlpool:
Whirlpool baths at body temperature usually reduce pain on a temporary
basis.

e) Electrotherapy:
Reflex heating:
1- Heat is applied to the torso or opposite extremity or on the abdomen, and not
directly to the affected extremity.
2- This cause vasodilatation and general increase in blood flow
3- Blood flow is than increase to the ischemic extremity
4- Reflex heating is safer than local heating because it does not increase local
tissue temperature and metabolism.

Precautions:
1- A maximum target heart rate should be established during ambulation and
bicycling exercises
2- Avoid exercise during very cold weather
3- The patient must wear shoes that fit properly and will not cause skin
irritation.
4- Cardiac patient must be monitored during exercise.
5- Exercise and elevation of the limb are discontinued if pain or cramps of the
calf muscle occur.

Contraindications:
1- Patients with resting pain should not participate in an ambulation or
bicycling.
2- Patient with ulceration of the feet and wounds or fungal infection should not
participate in walking programs.

22
 3- Buergers exercise are contraindicated in:
a) Recent acute thrombosis or embolus.
b) Increased swelling in lower extremity.

II) THROMBOANGITIS OBLITERANS:

Thromboangitis obliterans (buergers disease) is an inflammatory occlusive
vascular disorder involving small and medium sized arteries and veins in the
distal upper and lower extremities. It may affect males between 20 and 40.
The cause is not known, there is definite relationship to cigarette smoking.

Clinical features:
1- Typical patient with buergers disease is male cigarette smoker between20-40
years.
2- Intermittent claudication is usually confined to the lower calves and feet or
forearm and hands.
3- There is rest pain and feet are cold, sweating, and often have fungal infection.
4- On elevation feet becomes pale and on dependency it becomes red.
5- With further progression there is severe digital ischema, trophic nail,
ulceration and gangrene may develop at the tips of the fingers.
6- Pain is associated with onset of gangrene is severe and may prevent sleep.

Treatment:
1) Medical:
- Analgesics, vasodilator and antibiotics.
- Smoking is forbidden
- Skin hygiene is essential to prevent wound infection.
- If these measures fails, surgery may be required.

2) Physiotherapy:
Aim:
- To prevent complications of bed rest such as bed sores, blood stasis and
respiratory deterioration
- To improve circulation to the affected limb so to delay onset of gangrene
- To relief pain as possible.

23
 Methods:
a) Positioning:
Long sitting with well supported back and neck.
Lower limbs must be lowered by 7 inches below the horizontal level, to
decrease pain and improve perfusion.
Avoid compression of the calf muscle to prevent DVT and maintain blood
flow to the digits.

b) Massage:
Gentle effleurage or kneading (after the acute onset and with permission).
Slight elevation of the limb during the application of the massage and note
to be gentle not to cause pain and abrasion of the skin.
Painful areas must be avoided.

c) Exercise:
Daily grade ambulation.
- Stop when pain appears.
- Rest than continue walking.
- Begin with 5 min/ secession, and gradually to progress up to 60 min ( 1/2 at
morning &1/2 at evening)
- Walking on level and on an incline.
- Proper shoes selection to avoid compression and lesions to the digits.
Buergers-Allen exercise.
Stationary bicycle as graded walking.
Mild warm up activities prior to initiate walking or bicycle. Warm up
activities could include static stretching of calf muscle and active isotonic
pumping exercise of ankle and toes.
Precautions and contraindications of exercises as in atherosclerosis.

d) Electrotherapy:
Heating:
- Direct heat such as whirlpool, irradiation , hot packs, hot water bottle, or
shot wave diathermy
- Indirect heat ( reflex heating)

24
 - N.B: heat must never be applied where spasm cannot be relived as this only
produces local vasodilatation which without an increased blood supply
causes tissue damage.
Iontophoresis:
Mecholyl 0.25% solution is used to produced vasodilatation through positive
electrode.

Contraindication in electrotherapy:
1- Severe cardiac cases
2- Hypotension
3- Disturbed sensation
4- Ischemic areas
5- Sensitivity to heat and Iontophoresis.

III) RAYNAUSS PHENOMENON:

Raynauds phenomenon refers to intermittent attacks of ischemia of the
fingers or toes, and sometimes of the ears or nose, secondary to intense
arterial vasospasm in the skin.

Signs and Symptoms

Typically, Renaulds phenomenon has triphasic color changes
a) pallor and is often accompanied by paraesthesia and pain.
b) Cyanosis and is often accompanied with sensation of cold and numbness.
c) Rubor hypremic phase, occur with rewarming patients often experience
a throbbing painful sensation. Although the triphastic color response is
typical of Raynauds phenomenon, some patients may develop only pallor
and cyanosis ; others may experience only cyanosis.
Between episodes of arteriospasm there are no physical findings in patient
with primary Raynauds.
In secondary Raynauds phenomenon, the physical findings including pain,
tingling, dulling of sensation, numbness, and digital ischemia occur and
sustains.

Complications
1) Raynauds disease:

25
 a) Ischemic ulceration of tips of the digits may occur, often secondary to
trauma.
b) Rarely, amputation of a part of a digit may be necessary.

2) Secondary Raynauds phenomenon :

a) Digital arterial occlusions may occur with resultant ischemic changes and
even gangrene.
b) Scleroderma or rheumatoid arthritis, develop.

Physical therapy

a) Massage:
Effleurage, kneading and connective tissue massage may provide a
symptomatic improvement in this condition.
- The sacral and lumbar basic area should be treated first and then the
extremities. This reduces tension in the back and the patient often feels the
extremities becoming warmer.
- A course of connective tissue massage is often of benefit prior to the advent
of winter.

b) Active exercises:
Active exercises may be given to increase the flow of the general condition.
c) Heat:
(Heat must never be applied during an attack).
Radiant heat or short wave diathermy may be given with a low intensity to
avoid burning.
Reflex heating is more safety.

d) Contrasting baths:
- Contrast bath may help.

26
 The patient is instructed to place the hands or feet in a hot bath for 3 minutes
and then cool bath for 1 minute.
This can help to accelerate the rate of blood flow in the peripheral vessels.

e) Iontophoresis:
Iontophoresis is especially valuable for disorders with associated arterial
spasm.
To apply histamine, a thin cotton felt or filter paper pad which has been
soaked in a 1:1000 solution of histamine acid phosphate is placed over the
area to be treated.
Over this pad is placed a sheet of metal foil, slightly smaller than the pad, to
which the positive pole of the direct current generator is attached.
A larger dispersive pad wet with saline is connected to the negative pole.
The pads are fastened to the patient by an elastic bandage.
A current of approximately 0.3 to 0.5 mA per square centimeter of pad
surface is applied for three to five minutes.
Histamine may also be applied as 1 per cent histamine ointment rubbed onto
the skin and covered with a moist saline pad electrode.

f) Ultraviolet:
General ultraviolet radiation, with caution also may improve the condition of
Raynauds disease.

IV) CHILBLAINS

This localized inflammation of the superficial tissue. The toes, heels, hands
and fingers frequently suffer, and occasionally the ears or even the nose.

Signs and Symptoms:

1- The affected part is red, congested and swelled.
2- Swelling attended with severe itching and burning sensation to cold.
3- Erythema pernio (reddening of the skin).
4- Intense pain due to the irritation caused by the congestion and ischemia.
5- The affected heels may make walking impossible, and pressure on the
inflamed parts causing intense pain.

27
 Management:
a) Medical:
1- Vasodilators drugs, and correction of blood calcium content.
2- Avoidance of exposure to cold.
3- Penicillin ointment is often used in a broken skin.

b) Physical therapy:

1- Galvanic or sinusoidal baths.

2- Calcium ionization by Iontophoresis.
3- Ultraviolet light.
4- Zinc ionization by Iontophoresis in skin lesions and small ulcers.
5- Exercises ( Avoid robust types ).
6- Reflex heating.
7- Carbachol ionization.

- Broken chilblains should be dressed with ointment spread on lint (penicillin).

Finger kneading should be given round it, and ultraviolet light or zinc
Iontophoresis may be given to prevent sepsis and promote healing.

B) DISEASES OF THE VIENS:

I) VARICOSE VEINS:
28
 Varicose veins are dilated, elongated and tortuous superficial veins of the
lower extremities. They are caused by incompetent valves and increased
intraluminal pressure. Varicose veins can be categorized as primary and
secondary. Primary Varicose veins originate in the superficial system and
occur twice as frequency in women as men. Secondary Varicose veins results
from deep venous insufficiency and incompetent perforating veins.

Etiology:

1) Primary Varicose veins results from hereditary weakness of the vein wall and
valves.

2) Secondary Varicose veins are a sequel to deep venous thrombosis resulting

from: a) dilatation of the collateral vein.
b) Damage to the valve of deep vein.
3) Other contributing factors:

a) Obesity: due to an external pressure on the veins, especially in the

iliofemoral vein.

b) Orthostatism: this related to prolonged standing as in certain occupation, as it

develops high gravitational pressure within the vein. The pressure in leg
veins is 5-10 folds greater in erect position than in recumbent position.

c) Other conditions as pregnancy, ascetics, congestive heart failure, or pelvic

tumors.

Symptoms:

Symptoms vary in degree. No symptoms in less severe cases and often

concerned about the cosmetic appearance.
Aching in the legs, aggravated by standing, and relived by elevation.
Fatigue, pain in the legs with difficulty in walking.
The legs feel heavy and occasionally mild ankle edema develop.
Superficial venous thrombosis may be a recurring problem and rarely
varicosity rupture and bleed.

Complications:
29
1- Bleeding following rupture of the vein.
2- Venous ulcers due to devitalized skin.
3- Superficial venous thrombosis
4- Edema particularly in the foot and ankle.

Management:
a) Conservative:
- Avoid prolonged standing, sitting, obesity or constricting garments.
- Shower or bathes in the evening.
- Apply well fitted below knee support stocking (20-40mmHG) before
ambulating in the morning or exercising.
- Elevated feet 10-15 minutes 3-4 times daily

b) Physical therapy management:

Aim of physical therapy is to assists venous return and avoids venous stasis
and its complications.
1) Positioning:
Patient should lie on bed with legs in vertical position supported on the wall.
It is difficult for some patients to get in this position and modification have to
be considered and the position varies.
The patient is asked to practice this method frequently for period of 20
minutes at least twice daily.
Resting in this position may reduce edema by removing the gravitational
effect and reducing venous hypertension.
2) Intermittent compression:
Definition:
It is pneumatic unit designed to reduce edema by giving controlled,
alternating external pressure.
Intermittent compression reduces edema by moving excess interstitial fluid to
sites of normal lymphatic or venous drainage.
Pressure needs to be higher distally and lowered proximally.
Preasure may decrease pain and improve range of motion.

Contraindications:

30
 Presence of thrombus that could become mobile.
Edema related to cardiac dysfunction or from kidney dysfunction.
Infections.
Arterial insufficiency and increased peripheral resistance.
Obstructed lymphatic drainage
Unconscious patients

Indications:
Traumatic edema
Venous insufficiency
Lymphydema post mastectomy
Amputations

Procedure:
1- Instruct the patient about the procedure
2- Evaluate and inspect the skin carefully and take circumference
measurements (repeat after treatment).
3- Girth measurements: Performed while patient supine. Using a skin
pencil, therapist locate bony landmark and then makes measurement
marks every two inches above and below this point. Circumference is
measured at each marking.
4- Place the patient in a comfortable position
5- Place a stocking over the area with all wrinkles smooth.
6- Apply the appliance and attach the rubber tubing to the source of air.
7- Increase the pressure but do not exceed diastolic pressure.
8- Apply the pressure for 45-90 seconds and release for 15-30 seconds (3:1
ratio).
9- Ask the patient to keep moving his extremity.
10- Treatment for a minimum of 2 hours every 24 hours.
11- Remove the appliance and check the skin hourly
12- Recheck the skin and blood pressure when done.
13- Wrap the extremity with an ace bandage to keep the pressure and integrate
elevation and exercise.

31
14- It usually takes 3-4 weeks to achieve the desired effect.

3) Bandaging:
Aim: Correct bandaging is very important in the management of edema,
augmenting the muscle pump mechanism, and of supporting distended veins.
Local pressure should be applied by well shaped pad to the malleolar
hollows, the ulcer, and over varicose. These are held in place by a creep or
conforming bandage in a careful pattern and this should be retained when the
limb is dependent.
Bandage should be removed and replaced several times during a day in order
to vary the pressure imprint of the pattern of the bandage on the skin.
Bandage should be applied from the web of the toes to the tibial tubercle.
Applied firmly over the foot and ankle at approximately half stretch, the
bandage is applied with successively less tension as the pattern ascends the
leg
The therapist must check up pulsation of the extremity and also the normal
color of the skin.
Faradic stimulation can be applied with the bandaging to improve venous
return and to maintain muscle power of the extremities.
Application of bandaging should be done from supine position, and also
release from this position.

4) Massage:
Massage is an effective method in reducing edema if the patient can
tolerate firm pressure
Slow, firm effleurage starting proximal to the edema and gradually moving
distally.
Slow deep kneading and squeeze kneading is used to soften the edema,
followed by effleurage in order to express the fluid proximally.
Thumb and finger kneading manipulations are used below and behind the
malleoli, sole of the foot, dorsum of the foot and toes.
Care must be taken to avoid the ulcer and its surrounding skin in poor
conditions.

32
 5) Exercise:
1- Exercises must be done with the pressure support bandage or elastic support
stocking.
2- Exercises mostly applied from elevated position
3- Muscle contraction and joint movement within the constraint of a tight
bandage plus elevation; effectively augment the normal muscle pump
drainage of the limb.
4- Exercises should follow distal to proximal pattern.
5- Patient is encouraged to practice foot and ankle in elevation.
6- Patient is instructed to walk 1-2 KM a day with elastic stocking or bandage.

II) VENOUS THROMBOSIS:

Lesions in veins may produce local thrombi in small veins or extensive

thrombi in large veins. Classically it is associated with: venous thrombosis,
changes in veins wall, hypercoagulable state.
The lesions of endothelium, relative stasis of venous blood flow, and
hypercoagulability of blood are three identified factors that precipitate
venous thrombosis.
Venous thrombosis may be superficial or deep.
Superficial venous thrombosis (thrombophlebitis and phlebothrombosis)
Thrombophlebitis: refers to an inflamed vein as a result of thrombus.
Phlebothrombosis: is probably the same entity but does not exhibit a marked
inflammatory component.
Deep Venous thrombosis: refers to either thrombophlebitis or in the deep
venous system of the legs phlebothrombosis.

Clinical feature:

a) Superficial vein thrombosis:

Occur in the greater or lesser saphenous vein.

Patient complains of pain localized to the site of a thrombus.

33
 There is a localized redness, warm area with hard cord-like swelling along
the course of the affected superficial vein.
Pain may be present at rest and is aggravated by movement of the limb.
As the condition resolves the skin become pigmented along the course of the
vein.
b) Deep venous thrombosis (DVT) :

Occur less frequently in the upper extremity then in the lower extremity, but
the incidence is increasing because of the greater utilization of subclavian
vein catheter.
DVT can occurred at the iliac, femoral, popliteal, calf and soleous veins.
Unilateral leg swelling, warmth and erythema.
Tenderness may be present along the course of the vein and a cord may be
palpable.
There may be increase tissue turgor (swelling), distension of the superficial
veins and appearance of prominent venous collaterals.
Aching or cramp- like pain at the site of thrombus.
Increased pain in the calf on passive dorsiflexion of the foot (Homans sign).
Edema around the joint distal to the thrombus.
Severe pulmonary embolus given sign of extreme distress, breathlessness,
and shock may be the first indication of DVT.
In case of axillary vein atherosclerosis , it become tender, prominent and
enlarged with pitting edema in the forearm and hand. Superficial veins of the
entire arm are prominent and those of the pectoral region on the affected side
may be distended.

Treatment:

a) Superficial vein thrombosis:

Therapy is primarily supportive.

34
 Patient can be placed at bed rested with leg elevated and application of warm
compression
Drug therapy as antibiotics, analgesics and anti-inflammatories.
Firm elastic bandage or stocking from the toes to beyond the upper limit of
the affected area.
Exercises must be encouraged to carry out foot exercises with the legs
elevated and to remain ambulant to maintain venous circulation. In severe
cases patient may be confined to bed for short periods.
If thrombus of great saphenous vein develops in the thigh and extend to
toward the saphenofemoral vein junction, it is reasonable to consider
anticoagulant therapy to prevent extension of the thrombus into the deep
system and a possible pulmonary embolism
Resolution of the symptoms may take 7-14 days.

b) Deep venous thrombosis (DVT) :

Prevention is better than cure and early diagnosis is important for effective
treatment.
1- Leg pain and swelling may be alleviated by bed rest, leg elevation, local heat
and analgesics.
Bed rest not only alleviate leg pain and edema but also allows the thrombus
to organize and adhere to the vessel wall, a process that generally require 24-
72 hours.
Bed rest is continued until leg swelling and tenderness resolve.
For calf thrombosis, bed rest usually takes a week.
For iliofemoral thrombosis 10-14 days may be required.
2- Medical treatment: anticoagulant and thrombolytic therapy.

Physical therapy:

a) Position:

35
 Patient should rest in bed with elevation of the involved extremity for 5-10
days depending on the clinical extent and response.

b) Heat:

Application of moist heat (380) such as hot packs to the entire leg of the
involved extremity.
Aim of heat application is to relive the pain in acute inflammatory period.
c) Exercise:

These include breathing, foot and leg exercises. Also early ambulation and
advices to the patient in stable cases.
General breathing exercise after stabilization of the case.
Foot and leg exercises: active movements of hips, knees and particularly foot
and ankle for patients on prolonged bed rest. Also passive movements are
applied in paralyzed lower extremity.
Ambulation: early ambulation as the symptoms subside and with graduation
(start with 3 min. then graduated to 30 min. 2 times/day),the legs wrapped in
elastic bandage up to the knee , or elastic support stocking (30-40mmHG) to
reduce pain and swelling. The elastic support is continued for minimum of 2-
3 months.
- Advices to the patient: avoid sitting or standing still for any length of time.
Rest with legs elevated or walking is encouraged. Avoid crossing legs in
sitting or in supine position.
d) Massage:

Massage may be given to the thigh, front and outer side of the leg.
If femoral vein is affected, inner side of the thigh is avoided, in case of
popliteal vein thrombosis avoid popliteal area.
A few days later if the condition progressed gentle kneading massage may be
added.

Surgical treatment:

36
 Thrombectomy is performed as soon as possible after onset, as the chance of
survival of the limb decreases with time.

Complications: pulmonary embolism, postphelebitis neurosis and chronic

venous insufficiency.

III) CHRONIC VENOUS INSUFFICIENCY:

Chronic venous insufficiency is chronically impaired venous outflow

from the extremity and inadequate return of blood to the heart.

Clinical signs and symptoms:

Signs:

Dependent edema: associated with standing and sitting for prolonged periods
of time, usually worse at the end of the day, edema decrease if the legs are
elevated.
Presence of superficial varicose veins. Erythema, dermatitis,
hyperpigmentation develop along the distal aspect of the leg, skin ulceration
may occur near medial and lateral malleoli.

Symptoms:
Patient with venous insufficiency often complain of dull ache in leg that
worsen with prolonged standing and resolves with leg elevation. The dull
ache pain is being severe with standing still rather than when walking. Pain
disappear within 5-30 minutes after recumbent position with legs elevated.
Nocturnal muscular cramps may be reported.
Heaviness of the limb during walking or in bed movement.

Complications:
Stasis changes typically in the medial aspect of the lower legend ankle
Recurrent venous thrombosis is favored by venous stasis.

Treatment:

37
 a) Prevention:
- Prompt and adequate treatment of DVT.
- Adequate treatment of varicose veins.

b) Physical therapy :
- Adequate elastic support
- Stasis, dermatitis and ulceration
1- Bed rest
2- Elevation of the foot of the bed
3- Moist dressing of sterile normal saline
- Increase venous return and reduce edema:
1- Manual massage of the extremity in distal to proximal direction
2- Intermittent compression pump
3- Regular ambulation or active exercise program
4- Individual tailored pressure gradient support stocking should be worn
during ambulation.
c) Ancillary treatment:
1- Weight reduction
2- Avoid extra salt
3- Anticoagulant therapy

C) LYMPHATIC DISORDRES:

38
 The extremities are richly supplied with lymphatic vessels that function to
return tissue fluids to the venous circulation from the extremities.

Lymphydema:

Lymphydema is swelling of extremities or rarely the face and genetalia, due

to malfunction of the lymphatic system as obstruction of lymphatic vessels.

Signs and symptoms:

Lymphydema of the distal extremity seen over the dorsum of the hand or
foot.
Increase weight or heaviness of the extremity.
Sensory disturbance of hand or foot.
Stiffness, tautness of the skin and increase suitability to skin breakdown.
Decrease resistance to infection, causing frequent episode of cellulitis.
Gradual increase swelling of the affected part usually unilateral. Primary
Lymphydema begins distally and spread proximally but secondary
Lymphydema may begin proximally.
Initially edema pit on pressure but later it becomes solid.
Enlargement of regional lymph glands in secondary Lymphydema.
In chronic stage the limbs have woody texture.

Examination:
a) Obstructive:

Edema: In primary Lymphydema the edema begins as soft pitting form but
becomes harder and nonpitting with time. The condition can be unilateral or
bilateral.

Secondary Lymphydema is usually unilateral and considerable fibrosis may

occur.

Tissue vitality: Due to cellulitis, this leads to thickening and scaling of the
skin.

39
 Yellow nail syndrome: The nails appear yellow in color, thickened but
smooth and there is an increase in lateral curvature.

b) Girth measurements:

Limb measurements must be done at the set levels and ideally repeated by the
same person. These measurements are taken in:

1) The upper limb at:

Axilla
8cm proximal to the olecranon.
11cm distal to the olecranon.
Wrist
Level of web of the thumb
2) The lower limb at:
Groin
15cm above the base of the patella.
15cm below apex of the patella
Ankle
Middle of metatarsals.

Volumetric measurements of the extremities:

The involved extremity is immersed in a tank of water
Graduated cylinder is required.
Patient is positioned so that the extremity to be assessed can be submerged in
the volumeter.
The volumeter previously should have been filled and allowed to sit until all
dripping water from the spout has ceased.
As the extremity is placed in the container all displaced water is collected and
measured.
The amount of water is recorded.
Because the volume that water occupies is different at different temperatures,
it is suggested that careful attentionbe paid to assuring that the same
temperature water is used with each subsequent measurement.

40
 N.B: volumetric measurement is more accurate. It is particularly valuable
when measuring irregular surfaces.

Complications:
The complications of Lymphydema are:
- Infection
- Acute lymphangitis or cellulitis
- Lymphangitis is characterized by painful red streaks following the lymph
vessels, which may eventually involve the lymph nodes as well. Systemic
effect include increase temperature, malaise and chills with localized edema.

Treatment:
1) Medical:
- Skin hygiene
- Prophylactic antibiotics

2) Physical therapy:
a) Reduce Lymphydema:
Elevate the extremity above the level of the heart (30-450) while sleeping
and as often as possible during the day.
Manual massage from distal to proximal along the length of the
extremity.
Isometric and isotonic pumping exercise of the distal muscles.
Intermittent mechanical compression with a pneumatic pump and sleeve
for several hours a day.
Application of pneumatic pump:
All clothing and jewellery must be removed to avoid restricting the
circulation.
The limb should be supported and elevated during treatment.
The sleeve which is applied on top of a layer of tubigauze must include
all the hand and foot otherwise the circulation is restricted and the patient
complains of pins and needles.
Assessment of joint range and muscle strength of the the limb should be
recorded before treatment.

41
Procedure:
Pressure for upper and lower limbs is the same. Pressure cycle may be:
a) Fixed 30-45 seconds inflation and 15 seconds deflation.
b) Variable inflation time can be increased to 60 seconds.
Suitable outline plan:
1) Begin with 40mmHG for 30 min. and assess immediately and hour later.
2) Repeat treatment twice daily.
3) Pressure is kept the same and time is gradually increased up to 1 hour at the
end of the week with 40mmHG pressure.
4) In the second week increase the pressure by 5mmHG per day until 65mmHG.
5) Treat for 1 hour twice daily.
6) If patient complain of pain use a lower pressure and more frequency.
e.g. 45mmHG three times daily or 30mmHg four times daily.

b) Prevent further edema:

Elastic support stocking or sleeves individually measured and fitted to the
patient.
Regular elevation of the extremity.
Avoid sources of increased load on lymph vessels as:
- Static dependent position of the limb.
- Application of local heat.
- Hot environment.
- Prolonged use of muscle for even light tasks.

c) Soft tissue manipulation:

Before applying pneumatic compression give massage around each shoulder
region, it helps to promote circulation proximally.
1) Begin with deep kneading or squeezing, kneading if the tissue are
stretched followed by clearing effleurage to the axilla.
2) Finger or thumb kneading is used for localized thickening.

d) Electrotherapy:

42
 Faradic current under bandaging and with elevation is being a valuable
method of improving the edema, by exerting pressure on the veins and
lymphatic vessels. As the bandaging restrict the direction of movement of
muscle fibers.

Advices to the patient:

Use the limb as normal as possible
Avoid injections on the affected side
Avoid hot bathes since the limb will swell further. Cool bathes are allowed.
Dont wear tight clothes or rings on the swollen limb.
Elevate the limb by putting the lower limb on a chair during the day and raise
the foot of the bed at night. Support the upper limb in a sling or sit for short
periods with the hand on the head.
Dont carry heavy cases with an affected limb.
Wear footwear that support the foot
Avoid minor injuries such as scratches which provide an entry for
infection. If the area becomes red, swollen or hot, seek medical advice as
soon as possible.

43